Name

First Name

Last Name

Have you experienced significant emotional distress or upheaval that affects your day-to-day functioning?

Yes

No

Maybe

Are you open to exploring and addressing your family history's potential influence on your current struggles or challenges?

Yes

No

Maybe

Do you feel motivated and prepared to actively engage in therapy sessions to address past experiences and patterns?

Yes

No

Maybe

Are you seeking long-term healing and growth rather than just short-term solutions to your current challenges?

Yes

No

Maybe

Have you noticed changes in your emotional well-being or physical symptoms linked to stress or past experiences?

Yes

No

Maybe

Are you prone to experiencing panic attacks, anxiety spikes, or heightened stress reactions in specific situations?

Yes

No

Maybe

Do you struggle with establishing healthy boundaries in relationships or notice patterns from your family of origin?

Yes

No

Maybe

Are you interested in exploring generational patterns or dynamics within your family history?

Yes

No

Maybe

Are the symptoms you're experiencing manageable with non-crisis therapy once a week, or do you need a higher level of care?

Manageable with help

I need a higher level of care

I'm not sure