intake form - kalaharihealingarts

Welcome to Kalahari Healing Arts. We’re honored that you’ve chosen to begin or continue your healing journey with us. This intake form helps us understand your needs, experiences, goals, and preferences so we can offer care that is respectful, personalized, and aligned with your values.

What brought you to schedule this consultation today?

How is this concern affecting your daily life, relationships, work, or overall functioning?

What steps or supports have you already tried to address this concern?

What has been helpful so far, and what hasn’t worked for you?

Are you currently experiencing any thoughts of harming yourself or others?

If yes, do you have a plan or intent at this time?

Have you had any unusual experiences, such as hearing voices, seeing things others do not, or feeling disconnected from reality?

Have you experienced beliefs or perceptions such as feeling watched, thoughts being controlled, mind-reading, or feeling that media messages are directed specifically at you?

On a scale of 1–10, how important is it for you to address this concern right now?

On a scale of 1–10, how ready do you feel to begin therapy and engage in the healing process?

Full name:

Date of Birth:

Phone Number::

Email Address:

Mailing Address:

Insurance company name :

Insurance Claims Mailing Address (back of card):

Insurance Provider Phone Number (back of card):

Insurance ID Number:

Group Number: