Intake Form

Wholebeing Wellness Counseling

Intake Form

Dr. Valentine McKay-Riddell, PhD, MACP

505-780-5990

wholebeing@orenda-arts.org

vmckayriddell@gmail.com

 

Welcome to Wholebeing Wellness Counseling.  I look forward to meeting and talking with you.  Here are a few questions to consider.  Please answer these and return them to me before or during our first meeting.

 

1. How did you hear of Wholebeing Wellness Counseling?
   1. Website, Facebook, Twitter, etc.
   2. Psychology Today website
   3. Referral
   4. Other (Please explain)

 

 

2. What are your major concerns at this time?
   1. Life changes
   2. Relationships
   3. Physical, psychological, or emotional issues (please list)
   4. Spirituality
   5. Addictions
   6. Other (Please explain)

 

3. Lifestyle questions
   1. Are you currently taking pharmaceutical medications? (Please list)
   2. Are you currently using recreational drugs? (Please list)
   3. Are you currently taking supplements? (vitamins, minerals, herbs, homeopathic remedies, etc.  Please list)
   4. Do you follow a particular diet? (regular, whole foods, Ayurvedic, macrobiotic, paleo, etc.)
   5. Do you use alcohol? (How much?  How often?)
   6. Do you drink coffee? Tea?  Other caffeinated beverages?  (How much?  How often?)
   7. Do you work? Part time?  Full time?
   8. Are you a student? Part time?  Full time?
   9. Are you a returning veteran, or do you live with or care for a returning veteran?
   10. Are you retired?
   11. Please briefly describe a typical day and night in your life.

 

4. What has been your previous experience of counseling, if any?

 

5. How may I best be of help to you at this time?

 

 

6. Is there any additional information you’d like to share?