Confidential New Client Intake Form

Confidential New Client Intake Form

The intention of this form is to provide an idea of where you are in your cancer experience, what you’re currently doing and what you are looking for. There are several approaches to cancer care that can be adapted to your needs and interests. Your answers to these questions will help me know how best to support you. Contrary to popular belief, the type of cancer and its stage are not always the key determinants of your choices. While important, YOU are the key to creating a treatment plan – not the cancer. Please take the time to fill this out thoughtfully. We will use it and I will keep it confidential.

  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 10 to 100.
  • Date Format: MM slash DD slash YYYY
  • About my Cancer

  • Date Format: MM slash DD slash YYYY
  • Prescription Drugs and Over-the-Counter Medications
  • I eat or drink: (Rate the following on a 0­‐10 scale where 0 is never and 10 is always)

  • Servings per Week

  • I take or use the following: (D=daily S=several times a week O=occasionally N=never)

  • Dentistry

  • Immune System

  • Detoxification

  • Sleep

  • Stress

  • What do you consider your 5 top stressors (ie: financial, marital, job, cancer, other health issues, children, parents, other relationship) List in order of greatest to least.

  • Emotional traumas (past and current and including significant losses) List known major emotional traumas and identify if past/current (p/c) resolved/unresolved (r/u)

  • Career

  • If working, please rate the following from 1-10 with 10 being high degree and 1 being minimal

  • Authentic Expression and Life Purpose: Please rate 1-10 with 10 meaning very strongly so

  • Self esteem: Please rate 1-10 with 1 being barely and 10 being very strongly so

  • Relationships: Please rate the following from 1-10 with 10 being strong agreement

  • Spirituality: Rate the following from 1-10 with 10 meaning you strongly agree

  • Related specifically to your cancer challenge, please rate from 0-10 (with 10 being the strongest) your degree of:

  • HealtheCare/Self-care: Rate on a scale of 1-10 with 10 being very well

  • Advocate/Support Team: Rate on a scale of 1-10 your level of agreement (0 meaning no agreement and 10 full agreement)

  • My top 5 reasons for living or staying alive are: