On-line Intake Form — Robynn Bliss

Please fill out each box in this Client Intake Form.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Preferred Communication:

Text

Phone Call

FaceTime

Skype or Zoom

Birthdate

Emergency Contact with phone #

Are you currently under a doctor's care?

Are you currently taking any prescription medicine?

Marital Status

Do you have children? (If yes, please list them, including names, and three or four words that describe their personality.)

Why are you seeking spiritual direction?

To give me a sense of your story, please write a historical timeline of places you have lived:

. . . a historical timeline of significant life experiences (transitions, accomplishments, disappointments, traumas, major changes):

. . . describe your relationship with your mother:

. . . describe your relationship with your father:

. . . describe your relationship with God. Is there a word picture that you can use to describe how you two relate?

What else would you like me to know about you?

Thank you for trusting me with this information. I will keep it strictly confidential.