KATE SHIPP, B.S., C-IAYT, ERYT500, YACEP, RMT New Client Intake Form KATE SHIPP, B.S., C–IAYT, ERYT500, YACEP, RMT NEW CLIENT INTAKE FORM Please complete this in as much detail as you feel comfortable. If you do not wish to answer a question or area, or do not know the information, please leave it blank. "*" indicates required fields Step 1 of 6 16% Today's Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Identification Preference:* She He They Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Current Occupation:* Referred By:* May I add you to my email list?* Yes No Experience in the following:* Yoga Yoga Therapy Meditation Reiki or other energy medicine practices Life Coaching Breathwork Select AllAny Prior Therapy (ie. Talk Therapy, Trauma Therapy, EMDR):*Briefly outline your personal support system (i.e., family, friends, groups):Emergency Contact Name* First Last Emergency Contact Phone* General Health InformationNote: The following information requested, if you choose to provide it, will help me to work more effectively with you. Please fill in the following section for any condition for which you have been treated in the past two years. General Physician:Provider Name | Condition | Approximate Dates of TreatmentPsychotherapist/Psychiatrist:Provider Name | Condition | Approximate Dates of TreatmentChiropractorProvider Name | Condition | Approximate Dates of TreatmentHomeopathic or Naturopathic PhysicianProvider Name | Condition | Approximate Dates of TreatmentOther (please list):Provider Name | Condition | Approximate Dates of TreatmentPlease list below any prescription or non-prescription medication you're taking:Describe any recreational drug use past or current.Describe any current addictions, including food, alcohol, cigarettes, work, sex, or social media.Please list any history, including dates, of surgeries, major illness, chronic conditions, accidents, injuries, or anything that might be relevant to and therapies that require movement or strenuous activities:Please check any condition which applies to you: Addiction Recovery AIDS Anxiety Arthritis Asthma Bulging or herniated disc, Degenerative disc disease Chronic Fatigue Syndrome Chronic pain Contact lenses (check only if you are wearing them now) Depression Eating disourder Emphysema or other treating problem Fibromyalgia Fatigue Fused vertebrae Heart condition Hernia High blood pressure Hepatitis History of physical, sexual and/or emotional abuse Joint replacement (hips, knee, shoulder) Low blood pressure Menopause Multiple sclerosis Neuropathy Osteoporosis Currently pregnant Prior Pregnancies C/PTSD (if diagnosed please let medical providers below) Length of time in Addiction Recovery: Location in the body of your chronic pain: Are you currently taking medication for high blood pressure? Yes No Type of Hepatitis: How many months pregnant: Type of Birth Vaginal Cesarean Both Number of PregnanciesNumber of Live BirthsC/PTSD Medical Provider: Some of this work may include physical touch. Please know that if at any time you do not want to be touched you have the right to request to not be touched. If you prefer all Touch-Free sessions, please initial here: Birth InformationPlease fill this out with as much information as you can or are comfortable sharing.Place of Birth: Number of Siblings:Birth Order: In what kind of facility were you born? Planned pregnancy? Yes No List any specific physical or emotional difficulties during mother's pregnancy with you.Provide any details you know about your mother’s labor or delivery?Provide any circumstances around your birth? (early or late, forceps, anesthesia, caesarean, breech, induced, cord around neck, etc.?)Provide any details you know about miscarriages, abortions, or fetal deaths before or after you.Describe the attitude of parents, siblings, or other family members regarding your birth. Infancy, Childhood & FamilyDescribe your parents’ relationship - past and present. Any other significant care givers?What qualities do you like about your mother, father, caregivers?What qualities do you not like about your mother, father, caregivers?Relationship status: Single Married Divorced Widowed Partnered If you are in a relationship, what qualities do you love about your partner? What do you wish would change?List name, age for each of your own children, if any. Emotional AnatomyDescribe any current or recent emotional issues.*Describe any prior emotional process work.*What is your negative self-talk about who you are?*What is your negative self-talk about life?* Spiritual AnatomyBriefly describe any spiritual or religious beliefs.What does a spiritual experience mean to you?What is the name you use to describe a Higher Power, if you believe in one?