New Client Intake — Embodied Heart Wellness
Embodied Heart Wellness
Jen Fuller, MA, LPC, RYT  ·  Lafayette, CO
New Client Intake Form

Thank you for your interest in working with me. Because I see clients in my home office, I have a brief intake and screening process for all prospective in-person clients. This is not a reflection of your worthiness as a client — it is a practical step to ensure that in-person sessions are the right fit for both of us.

If in-person sessions are not the right fit at this time, I am happy to offer virtual sessions via secure telehealth, or provide referrals to providers who may be a better match for your current needs.

Please complete this form prior to your 15-minute consultation. All information is kept strictly confidential.

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Basic Information
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What Brings You to Therapy
1. What are you hoping to work on or address in therapy?
2. How long have you been experiencing these concerns?
3. Are you currently in crisis or experiencing an acute mental health emergency?
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Mental Health History
4. Have you previously worked with a therapist or counselor?
5. Have you ever been hospitalized for a mental health reason?

Note: Hospitalizations within the past 10 years may affect eligibility for in-person sessions at my home office.

6. Are you currently experiencing symptoms of psychosis, including hallucinations, delusions, or significant breaks from reality?
7. Do you have a current diagnosis or history of any of the following? (check all that apply)
4
Safety
8. Are you currently having thoughts of harming yourself?
If you are having thoughts of harming yourself, please contact 988 (Suicide & Crisis Lifeline) or text HOME to 741741. Please answer the following questions so I can best support you.
a. Have you wished you were dead or wished you could go to sleep and not wake up?
b. Have you had any actual thoughts of killing yourself?
c. Have you been thinking about how you might do this?
d. Have you had these thoughts and had some intention of acting on them?
e. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
f. Have you done anything, started to do anything, or prepared to do anything to end your life in the past 3 months?
9. Do you have a history of suicide attempts?
10. Are you currently having thoughts of harming anyone else?
11. Are you currently in a domestic violence situation, or have you been in the past 12 months?

Active domestic violence situations require specialized support. I am happy to provide referrals to providers equipped for this work.

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Substance Use
12. Do you currently use alcohol or recreational substances?
13. Have you ever been treated for a substance use disorder?
14. Is substance use a primary concern you are seeking therapy for?

Active addiction is best treated by providers with specialized training. I am happy to provide referrals.

6
Legal Involvement
15. Are you currently involved in any legal proceedings related to mental health, domestic violence, child custody, or criminal matters?
16. Is your participation in therapy mandated by a court, employer, or other entity?

I am not able to provide court-mandated therapy or legal documentation of treatment.

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Session Format
17. What is your preferred session format?
18. Is there anything else you'd like me to know before our consultation?
Acknowledgment & Consent

By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that Jen Fuller, LPC reserves the right to determine whether in-person sessions are appropriate based on this screening, and that this decision does not reflect a judgment of my character or worthiness as a client. I understand that if in-person sessions are not recommended, I may be offered virtual sessions or referrals to other providers.

Thank you for completing your intake form.

I will review your responses and follow up within 1–2 business days to confirm your consultation or discuss next steps. I look forward to connecting with you.

Embodied Heart Wellness  ·  Jen Fuller, MA, LPC, RYT  ·  embodiedheartwellness.com

This form is confidential and protected under applicable privacy laws.