Counselling Intake Form

Intake Form

Physical History (please be accurate, medical records may need to be disclosed at some point)

Annamaya Kosha

Please enter the following information for any substances including alcohol, tobacco, and drugs that you currently use or have used in the past:

• Activity •Frequency • Length of time

Pranayama Kosha

Manomaya Kosha

Vijnanamaya Kosha

Anandamaya Kosha

Emotional Status

Present Situation

Personal Agreements

As your therapist/counsellor, you honour me by sharing your life and growth with me. I will not hide myself behind silence or position and will have high regard for you as a person. I will bring the best that I know from my study and experience. I will bring you the highest of my insight, wisdom, and support. I will keep a holistic perspective in our work together because I believe that the Physical, Spiritual, and Soul (mind, will, emotions) all work together to form the wholly healthy person. You can expect truth from me even when you may not want to hear it. I will always have compassion and empathy for you in all that we do. I value you as a person in need of care. I will do my best to honour that.

Kelly Ranford