Client Intake Form Name * First Name Last Name Birthdate * Phone Number * (###) ### #### Time Zone * Option 1 Option 2 Option 3 Option 4 Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### What is your relationship to your emergency contact? * Are you currntly under the care of a doctor or therapist? If yes please explain. * Do you currently have any Mental Heath Diagnosis? If yes, please list and describe. * Are you currently on any medication? If yes, please list and describe. * Are you currently or have you in the past suffered from any of the following? * (check all that apply) Abuse (emotional, verbal, physical, sexual, spiritual) ADD / ADHD Academic Performance Addiction Anger / Rage Anxiety Brain Fog Bullying Dementia \ Alzheimer's Depression Divorce of family separation Chronic Fatigue Chronic Pain Concussion , TBI or MTBI Eating Disorder Epilepsy Fear \ Panic Feeling Lost | Trying to figure out my path and purpose Fibromialgia Focus Issues Grief \ Loss Hallucinations Headaches | Migraines Intrusive Thoughts / Torment Insomnia Learning Disorders Loss of a loved one Memory Disorders Neglect OCD PTSD (PTSI) \ Trauma Racing Thoughts Rejection \ Abandonment Relationship Struggles Religious Trauma Schizophrenia Seizures Self Harm Sleep Disturbances / Nightmares Spiritual Attack Stroke Suicidal Thoughts, Attempts or Ideations Traumatic accidents or experiences Trouble Forgiving others Trouble Forgiving Yourself Trouble making friends or finding authentic relationships What services are you interested in? * (Check all that apply) Faith Based Life Coaching Faith Based Trauma Resolution Coaching RET + Rapid Eye Technology MCN + Microcurrent Neurofeedback Stem Cell Activation Therapy MAP Method Coaching Brain Tap Training | Vibroacoustic Sound Lounge Deliverance & Inner Healing (please fill out the deliverance application in the menu) Do you Identify as a Christian? If yes, for how long? If no, what are your current beliefs? * (please describe) Were you raised in a Christian of Faith-based home? * Yes No Describe your relationship with your parents growing up * Do any of the following run in your family line? * (check all that apply) Addiction Abuse Divorce Mental Illness Suicide Poverty Witchcraft / Occult Incarceration Control \ Manipulation Rebellion False Religions/ Cults GOALS * What would you like to walk away with after your session? Are there any specific areas of breakthrough that you're believing for? Is there anything else you'd like to share about your goals, what you'd like to overcome or any other information that would help me understand your journey? * Disclaimer & Consent for Services * By submitting this form and participating in sessions with The Healing Room, you acknowledge and agree to the following: I understand that Abrey Adams- Watterson has been professionally trained in trauma-informed coaching, Microcurrent Neurofeedback, Rapid Eye Technology, and many other holistic methods that may be used during my sessions. I recognize that these tools, when combined with biblical principles and spiritual guidance, including prayer, inner healing, and deliverance ministry, can bring breakthrough and powerful support to emotional, mental, and physical healing. I acknowledge that while these services may be highly effective, they are not a substitute for professional medical, psychological, or psychiatric care. I agree to take full responsibility for my health and to seek licensed medical or mental health support when necessary, understanding that the services provided are meant to complement—not replace—such care. I understand that participation is voluntary and that I am solely responsible for any decisions, actions, or results that arise from these sessions. I agree to hold harmless Abrey Adams- Watterson and The Healing Room, LLC & Optimal Brain Center of Idaho from any and all liability related to my participation. I also understand that all personal information shared will be kept confidential unless there is a disclosure of intent to harm oneself or others, or if required by law. By checking the box below, I consent to receive spiritual support, prayer, and guidance rooted in Scripture and led by the Holy Spirit. I acknowledge that I am seeking faith-based services and do so of my own free will. Yes, I have read, understood, and agree to this disclaimer and consent to receive services. Cancellation and reschedule policy * I understand that my scheduled appointment time is reserved exclusively for me. In the event that I need to cancel or reschedule, I agree to do so at least 72 hours in advance in order to avoid any fees or forfeiture of services. If I cancel with less than 36 hours’ notice or fail to show up for my scheduled session (no call–no show), I understand this will be considered a cancellation. In such cases, the full session fee will be due. If I have purchased a package, the missed session will be deducted from my package balance. This policy is in place because last-minute cancellations often cannot be filled, resulting in lost income and limiting availability for others waiting to be seen. I acknowledge that Abrey’s schedule may book out 3 to 8 weeks in advance, and I understand that cancelling or rescheduling last-minute may result in a significant delay before I can get another appointment. I may reschedule my session once with at least 72 hours’ notice without penalty. However, if I attempt to reschedule a prepaid session more than once, or if I reschedule more than once with short notice, it will be considered a cancellation and subject to the cancellation policy and fees above. I understand that true emergencies can happen, and I trust that Abrey will show grace and work with me in such situations when possible. Communication is key, and I will make every effort to notify her as soon as possible if something unexpected arises. Yes, I have read, understand, and agree to the cancellation and rescheduling policy above. Thank you!
