Intake form | Earthways Healing

top of page

Home
- About
- Contact
Services
- Service Packages & Plans
Events
Incentive Program
Mindfulness
More

Use tab to navigate through the menu items.

Earthways Healing Intake Form

*First name

*Last name

*Phone

*Address

*Date of Birth

*Gender

*Emergency Contact Name

*Emergency Contact Phone Number

*Relationship to Emergency Contact

Insurance Information

*Insurance Provider:

*Policy Number:

*Group Number:

*Subscriber Name:

*Subscriber Date of Birth:

*Subscriber Relationship:

How did you hear about us?

Friend / Family

Website

Social Media

Other (please specify)

Mental Health History

*What brings you to Earthways Healing, LLC? (Please describe your current concerns.)

*Have you previously received any type of mental health services (psychotherapy, psychiatric services etc.)?

*IF Yes, please specify when and from whom / and for what?

*Mental Health symptoms currently experiencing (Please check all that apply):

Depressed mood

Anxiety

Intrusive thoughts

Substance use related issues

Panic attacks

Racing thoughts

Nightmares

Dissociation

Eating too much / too little

Insomnia

Delusions

Suicidal thoughts

Sleep issues

*Have you ever experienced any trauma / difficult experiences, natural disasters, emotional, physical, verbal and or sexual abuse / neglect (please explain any or all)

Medical History

*Have you ever been to the hospital or hospitalized for any medical issues? surgeries? please explain in detail.

Social History

*Please explain your family dynamics (immediate family). What does your social circle look like. Please explain any issues with your social life?

Legal History

Do you have any past, current and or pending legal issues?

If yes, please explain, any and all juvenile / adult charges and convictions.

Education

Education level

GED / HSED

High School

Associates

Bachelors

Masters

Doctorate

Thank you for taking the time to fill out the above information. This information is helpful for our practitioners / providers to assist you in your healing journey. ALL information is protected by Privacy and HIPAA laws.

Contact Me

Location:

1316 Fairfax Street, Ste. 103

Eau Claire, WI 54701

email: ewh@ewhealing.com

earthwayshealing@gmail.com

Tel: (906)281-6007

Thank you for visiting EWH website!

Hope to see you soon!!

bottom of page