Intake form | Earthways Healing

If you are interested in utilizing Earthways Healing's Therapeutic services please fill out the following form:

Earthways Healing Intake Form

First name

Last name

Email

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?

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.)?

No

Yes

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

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

Have you ever experienced any trauma / difficult experiences, natural disasters, car accidents, domestic violence, 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?

No

Yes

If yes, please explain, any and all juvenile / adult charges and convictions. Also, if you are on probation or parole, provide information here.

Education

Education level

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.

At Earthways Healing, LLC, we are committed to protecting your privacy and ensuring the confidentiality of your personal health information. We comply with the Health Insurance Portability and Accountability Act (HIPAA) to safeguard your personal and medical data.

Our practices adhere to strict standards for the collection, use, and disclosure of protected health information (PHI). Your information is used only to provide high-quality care and support your wellness journey.

If you have questions about how your information is handled, please contact us for more details on our privacy practices. Your trust is our priority.