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Home
About
Marty Wuttke
Dr. Stella Wuttke
Services
Services Overview
Neurofeedback
Sound Healing
Esoteric Acupressure
Meditation
Resources
Media
Projects
Science Blog
HealthPillars
Literature
Testimonials
Admin
Contact
Booking
News
FAQs
(805) 705 0052
Intake Form for Adults
Confidential personal history form for adults
A copy of this form will be sent to the email address you provide below as well as to
[email protected]
after it is finalized.
Step
1
of
7
0%
First and Last Name:
(Required)
Today’s Date:
MM slash DD slash YYYY
Email address:
(Required)
Phone:
(Required)
Address:
(Required)
Handedness:
Age:
Birthdate:
MM slash DD slash YYYY
Profession:
Referred by:
What is the main concern / problem / difficulty that you would like to address? What are your reasons for seeking neurotherapy?
What other therapies, services or techniques have your tried?
Do you have a regular meditation practice?
Yes
No
Would you like to have a free introduction into meditation (approx. 20-30 min)?
Yes
No
Have you ever been diagnosed with a mental health problem?
Yes
No
What was the diagnosis?
Name of physician / therapist who gave the diagnosis?
Have you had any of the following?
Stroke
Blood clot
Surgery lasting more than 4 hours
Chemotherapy
Diabetes 1 or 2
Concussion
High blood pressure
Heart Problems
Seizure
Select All
Personal Information
Are you content with your current situation at home, work or school?
Marital Status
(Required)
Single
Married
In Relationship
Separated
Divorced
Widowed
Name of Spouse or Partner:
Names and ages of your children:
Family Background
Please list any history of illness in your family (heart problems, high blood pressure, asthma, depression etc.):
Please briefly describe your relationship with your family.
Please describe any outstanding events which occurred during your mother’s pregnancy, labor and delivery or other details regarding your birth experience.
Please describe any outstanding events which occurred before school age (problems in motor development, health, language acquisition, major moves of the family, separation of parents, any traumatic events, etc.).
Were you adopted?
Yes
No
What age?
Please describe any information you have about events preceding and following the adoption. Use a separate piece of paper if necessary.
School
Please outline any difficulties at school both socially and academically.
Health
Are you in good general health at the present time?
Yes
No
Are you taking any kind of prescribed medication?
Yes
No
List all medications with dosage and frequency
eg. Name, Dose, Frequency
Do you drink alcohol?
Yes
No
Describe usage habits
Do you use any type of non-prescription drugs?
Yes
No
What kind and how often?
What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health?
What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive or don’t support your health?
List any health problems, operations, and/or major illnesses you have had in the past or are currently experiencing.
Have you suffered or are you presently suffering from any hearing or ear-related problems?
Yes
No
Please describe:
Are you currently involved in any kind of therapy?
Yes
No
Please describe:
Have you ever been in an automobile accident?
Yes
No
Please describe:
Have you ever received a blow to the head?
Yes
No
Please describe:
Please list other symptoms, conditions, irregularities, and concerns.
Other
Is there any other information you believe might be helpful to us in determining the suitability of our program for you? The more information about your mental/ emotional/ physical life that we have the better.
Please check all that apply:
Absent-Minded
Rarely
Sometimes
Often
Comments
Easily Bored
Rarely
Sometimes
Often
Comments
Difficulty Getting Organized
Rarely
Sometimes
Often
Comments
Difficulty Sleeping
Rarely
Sometimes
Often
Comments
Frequent Tiredness
Rarely
Sometimes
Often
Comments
Difficulty Regulating Eating Habits
Rarely
Sometimes
Often
Comments
Difficulty Relaxing
Rarely
Sometimes
Often
Comments
Moodiness
Rarely
Sometimes
Often
Comments
Goals / Outcomes
Please be specific with regard to the goals and outcomes you would like to achieve. How will you measure or evaluate the success of achieving your goals?
Goal 1
I will measure this goal by:
Goal 2
I will measure this goal by:
Goal 3
I will measure this goal by:
What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Rate from 0 to 10, with 10 being 100% committed)
Please circle one:
0
1
2
3
4
5
6
7
8
9
10
Hidden
Terms & Condition
(Required)
Text for agree consent form on history forms: I agree to the
terms and conditions of the Consent Form.
