Client Intake Form
Luminous Healing

Please Complete this form

(All Information is strictly confidential)

First Name

Last Name

Address

Phone

Birthday

Sex

Occupation

Marital Satus

1. Have you experinced any car accidents, whiplash, head, neck or spinal trauma?

2. Any deaths or losses that were traumatic?

3a. FAMILY HISTORY - How many siblings do you have and where are you in the birth order?

3b. What was your position in the family, and what were the age differences and genders? Did your siblings have any anxiety, depression, addiction or illness?

3c. Were Mom and Dad (or step-parents) emotionally available/unavailable? Did they give hugs and say "I love you"?

3d. What did Dad do for a living? Did Mom work or stay at home?

3e. Either parent critical/perfectionistic?

3f. Any physical or sexual abuse from anyone growing up?

4a. RELATIONSHIP HISTORY (outside the family) You left home at what age?

4b. Have you had any long term relationships? Marriages? Children? Ages? How are they doing? How is the marriage? Is your partner emotionally available?

4c. Any abusive relationships in your history?

4d. Any physical or sexual abuse as an adult?

5. Any anxiety, depression or addictions for you? Are you on any medications?

6. Work History: Occupation? Any work-related stress, abuse, or trauma?

7. Medical/Health History? Have you ever had any anesthesia for any reason? Chronic pain/illness?

Thanks for submitting!

Extended Form

Client Intake Form Luminous Healing

Client Intake Form
Luminous Healing