HEALING AND RESTORATION INTAKE FORM
Emergency Contact Information
How did you learn of TMM Healing and Restoration Services?
Do you practice Christianity?
Are you a part of church or ministry?
How would you describe your relationship with God?
How do you desire to grow in your relationship with God (spiritual goals)?
Are there any obstacles getting in the way of you meeting your spiritual goals?
Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?
Are you currently taking any psychiatric prescription medication?
Have you been prescribed psychiatric prescription medication in the past?
Have you been psychiatrically hospitalized in the past?
Do you currently experience any mental health symptoms?
Have you experienced mental health symptoms in the past?
Family Mental Health History: The following is to provide information about your family history. Please check all that apply.
If any boxes checked please indicate the family member affected.
Do you having any problems with your sleep habits?
If yes, select those that apply:
Are there any changes or difficulties with your eating habits?
Do you consume alcohol regularly?
Do you engage in recreational drug use?
Are you currently in a romantic relationship?
In the last month, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?
What are you hoping to gain from TMM Healing and Restoration Sessions?:
List areas do you feel we need to work on the most?
Please understand that Healing and Restoration is a spiritual process that requires a consistent commitment to growing in God. You have to be fully committed to the process, complete all assignments, and have a genuine desire/heart for God. Do you have any questions about the TMM Healing and Restoration Process?
By signing below, I am acknowledging that I have chosen to receive Healing and Restoration services. My decision is voluntary and I understand that during the course of treatment I need to discuss topics with truth, openness, and transparency. I understand that I must commit to a session package before booking.
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