Intake Form - Mind Body God

Client Intake Form

Please answer the following questions to the best of your ability. After completing the form, you will be directed to schedule your free call with me.

I know it’s a lot and the more detailed information you give, the more effectively we can use our time together.

Your information will not be shared.

Briefly describe your marital/ partner status. How many children do you have?

Are you currently attending a church?

Yes No Sometimes

What are your current beliefs about religion/church culture?

Were you raised in the church?

Yes No

At what point did you know something was wrong?

Were you in the Purity Culture?

Yes No Don't know what that is

How will or has leaving the church affected your family relationships?

What have you or will you lose if you choose to believe something different?

I am

How do you believe God feels about you?

How do you feel about God?

What were you accused of by pastors, leaders, and church people?

Why are you leaving or why did you leave the church?

Do you feel guilty?

Yes No

Are you ashamed?

Yes No

Do you have difficulty making decisions?

Yes No

Do you trust yourself?

Yes No

What do you think happens when you die?

Do you trust people?

Yes No Some

How would you describe God? Are you afraid of God?

Are you afraid of going to hell?

Yes No I don't believe in hell

Are you afraid of demons, spirits, or the devil?

Yes No I don't believe in them

What were you taught about demons, spirits, and the devil?

Have your beliefs about demons, spirits, and devil changed? Please explain

Were you ever told you had demons, spirits, or that you were evil? If so, please describe. Did they ever try to cast them out of you?

Did you ever go through church counseling? If so, please describe what type, why, the outcome and anything else you want to share.

Were you ever disciplined by church leaders? If so, please describe

Were you ever asked to leave a church? If so, please describe

What are you most afraid of? List your fears.

Have you been sexually abused? If yes, by whom?

Do you enjoy sex?

Yes No Sometimes

Do you believe women can cause men to sexually sin?

Yes No

Do you believe masturbation is wrong?

Yes No

Do you believe sex outside of marriage is sin?

Yes No I'm confused

Do you believe same sex attraction is wrong?

Yes No

Have you been sexually harassed by pastors, church leaders or members? If so, Please describe

Describe your beliefs about sin. What is your definition of sin?

How afraid of God are you?

How would you describe your parents and your upbringing?

Do you fell like you need to get advice before making big decisions? Are you codependent? Please explain.

Often, people are accused of being too independent, to strong, outspoken, controlling, jezebel, and more. Did this happen to you? Please describe

What medical and mental health conditions have you been diagnosed with?

When did your health issues start?

What medical and mental health conditions have you been diagnosed with? Please explain

What are your traumas?

On a scale of 1-5 (1 = low and 5= high), how willing are you to do what it takes to heal from your trauma?

1 = I just want someone to listen to me 2 = I'm only willing to try 3= I'm looking for a quick fix 4= I'll do it as long as I don't have go deep 5= I'm in! I'll do whatever it takes

What symptoms are you currently experiencing? Please include physical, emotional, mental, and spiritual symptoms.

Are you interested in learning healthy habits?

Yes No

What are you addicted to?

What bad habits do want to address?

What beliefs do you want help with?

What alternative or natural health methods have you tried?

Do you like yourself?

Yes No

Do you accept yourself?

Yes No

Do you love who you are?

Yes No

Do you believe you are able to heal?

Yes No

Do you believe you are worthy enough to heal?

Yes Nol

What drew you to me? Why do you want to work with me? What do you hope to accomplish in our work together?

Please list anything else you want me to know. Nothing is stupid or insignificant.

Disclaimer

I understand that Heather Silva (practitioner) makes no claims to diagnose treat, prevent, mitigate, or cure diseases and that no information granted during the course of a session is to be construed as medical advice. Each individual holds within them the power of self-healing and the power of choice. The ultimate responsibility for your health and for your choices lies with you. I, as the client, release the practitioner (above), Heather Silva, from all claims as a result of these healing sessions.

By typing your name , you are agreeing to the the disclaimer

Client Intake Form

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