Client Intake Form - The Nervous System Mentor

The Nervous System Mentor

Client Intake Form

thenervoussystemmentor.com · Judith McFadden

Strictly Confidential

Thank you for taking the time to complete this form before your session. Everything you share here is strictly confidential and helps me understand you - not just your symptoms - so that our time together is as effective and comfortable as possible. There are no right or wrong answers. Just share what feels true for you right now.

Personal Details

First Name

Surname

Date of Birth

Age

Email Address

Phone (daytime)

Phone (evening)

Country / Location

Occupation

How did you hear about me?

Health & Medical

GP / Doctor's Name

Date of Last Check-up

Any medications currently being taken?

Any diagnosed conditions (physical or mental health)?

Are you currently working with any other therapists, practitioners, or doctors?

What Brings You Here

In your own words, what is bringing you to this work right now?

Tick anything from the list below that resonates with you

Anxiety Chronic stress Burnout / exhaustion Sleep problems Trauma / PTSD ADHD Low mood / depression Panic attacks Emotional reactivity Chronic pain Fatigue / brain fog Digestive issues Confidence / self-worth Relationships Grief / loss Phobias / fears Disordered eating Dissociation / numbness Addiction / habits Motivation / purpose Fertility / reproductive Skin conditions Hypervigilance Other

Is there anything else you'd like me to know before we meet?

Body Awareness

Our body often holds what our mind hasn't yet processed. Please describe any physical sensations, tension, pain or discomfort you are currently experiencing.

Where in your body do you notice tension, pain or discomfort? Please describe the location and what it feels like.

How long have you experienced this?

Does it worsen when you are stressed or emotionally activated?

Any other notes about physical sensations or body symptoms?

Your Nervous System

These questions help me understand how your nervous system is currently operating - there are no wrong answers.

How would you describe your general energy levels day to day?

Wired / on edge Wired but tired Flat / depleted Very variable Fairly regulated

On a scale of 1-10, how stressed do you feel right now in your life?

1 10 5

Barely any stressExtremely stressed

Do any of your physical symptoms or areas of discomfort get worse when you are stressed, anxious, nervous, or emotionally overwhelmed?

Yes, noticeably Sometimes Not sure No

If yes, which symptoms and what tends to trigger them?

How does your body tend to respond when you feel stressed or threatened? (Select all that apply)

Heart racing / pounding Shallow or held breath Muscle tension / bracing Nausea / gut response Shutdown / freeze / go quiet Dissociation / feel far away Irritability / anger Overthinking / mental loops Skin reactions I'm not sure / don't notice

How easily do you recover from stressful events or difficult emotions?

Fairly quickly Takes a few hours Days, sometimes longer I feel like I'm always in it

How is your sleep?

Generally good Hard to fall asleep Wake frequently Sleep but wake unrefreshed Poor overall

Have you ever worked with a therapist, counsellor, or somatic practitioner before?

Yes No

If yes, what and how was it for you?

What does feeling better look like for you? What would you notice if things were shifting?

Is there anything you'd like me to know about how to best support you - any preferences, sensitivities, or boundaries around the work?

Consent & Agreement

All information shared in this form and in our sessions is held in strict confidence in accordance with GDPR. It will not be shared with any third party without your explicit consent, except where there is a risk of harm to yourself or others.

The work I offer supports nervous system regulation and is not a substitute for medical care. If you have a medical condition, please ensure you continue to work with your GP or specialist alongside our sessions.

I understand that this work is complementary and not a replacement for medical advice or treatment. I consent to my information being stored securely and used to support my sessions with Judith McFadden. I understand that sessions not cancelled with 48 hours' notice will be charged in full. I am happy to receive occasional emails about upcoming sessions, programmes, or resources. (Optional)

Signature

Please sign below using your mouse, trackpad, or finger on a touchscreen.

Full Name (typed)

Date

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Thank you

Your intake form has been received. I look forward to meeting you. If you have any questions before your session, please don't hesitate to get in touch.

thenervoussystemmentor.com

Background

Personal Trainer

Sports Physio

Performance Psychology

Emotional Freedom Technique

Rapid Transformational Therapist

EMDR Practitioner

Neuroaffective Touch Practitioner

Neuroscience Coach

Somatic Breathwork Facilitator

Happiness Alchemist

Expertise

Uncovering what's going on, when you've been told it's all in your mind

When no "Physical" reasons can be given

Birth Trauma

Narcissistic Abuse

Neurodivergence

Communicating and translating with the body on a somatic level

Nervous system regulation sessions in Tenerife and online to help calm anxiety, release stress and restore emotional balance.