SACRED FREEDOM Client Intake Form Date * MM DD YYYY Name * First Name Last Name Date of Birth * ex. 09/14/1981 City, State and Time of Birth * If unknown, put N/A Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### SMS Consent * I consent to receive text notifications from Sacred Freedom, with the option to opt-out at any time. YES MAYBE LATER BACKGROUND Please check dynamics you were exposed to/experienced before the age of 19. * Adopted (self) Adopted (siblings) Traumatic Birth Alcohol/Substance Abuse Physical Abuse Sexual Abuse Spiritual Abuse Suicide Chronic Illness/Disease Parentification Parental Gaslighting Death of a Parent or Sibling Absentee Parent Narcissistic Parent Mental Illness in Parent None of the Above I am * Single Married Separated Divorced Widowed Do you have children? If so, please their ages below along with their living at home full time, part-time, etc. * If not, put N/A Please provide a brief overview of different mental/emotional/spiritual growth work modalities you've tried in the past. Do you feel they were effective? Why/Why not? * Do you know your Enneagram Number and/or your predominant Shadow Type Personality Trait? If so, please list and include how long it's been since your most recent assessment. * If not, put N/A Do you know your Sun, Moon, and Rising Signs? If so, please list. * If not, put N/A Is there anything you'd like me to know before we begin? * Thank you for submitting your Intake Form!If you haven’t already, be sure to download your Pre-Session Journal Prompts.
