1:1 Expert Consultation Onboarding "*" indicates required fields Client InformationPlease list your full name:* First Last Phonetic SpellingPlease indicate either the phonetic spelling of your name OR a familiar word that rhymes with your name, for example, Mario Gonzalez: MAH-ree-oh gon-SAH-les; Anne Barowski: Anne Ba-ROFF-skee; Lisa Lamagna: Lee-sah / sounds like “lasagna”Date of Birth:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email:* Phone:*Gender:My racial and / or ethnic identity is:How did you hear about Dr. Julie's work?Goals and AspirationsWhat are your goals for this work as you know them now?Current areas of desired change (check all that apply): Relationship Challenges Perfectionism Time Management Relinquishment Related Issues Imposter Syndrome Delegation Concentration Anger Lying Overwhelming Energy Impulsivity Irritability Mood Swings Obsessive Thoughts Racing Thoughts Avoidance Low Mood Sleep Changes Suicidal Thoughts Appetite Issues Body Image Compulsive Eating Anxiety Chronic Pain Panic Fear Headaches Nervousness Overwhelm Relaxation Stomach Troubles Nightmares Sadness Loneliness Libido Changes Fatigue Intimacy Sexuality Alcohol Use Risky Activity Drug Use Trauma Ambition Career Satisfaction Coping With Medical Illness Legal Issues Making Decisions Money Management Friends Parenting Separation/Divorce Grief Guilt Medical HistoryPlease share any relevant medical history:Please indicate the date (approximately) of your last examination by your primary care physician.MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920List any medications you are currently taking (include dosage and prescribing physician if known).Have you ever received prior counseling of any kind? Yes No Please state when, where and with whom:HouseholdRelationship status:Choose Relationship StatusSingleMarriedDivorcedWidowedSeparatedDomestic PartnershipPlease list household members' names, ages, and any concerns you may have.Family HistoryWho raised you? Where did you grow up?Siblings and their ages:Please list any family member struggles (physical, emotional, psychological):Are you a member of the adoption/foster constellation? (Check all that may apply) Yes No Adopted/Fostered Person Birth parent Adoptive/Foster parent Other (sibling, child, grandparent, aunt/uncle, etc) Please explain here.Please indicate your age during key moments of your parents relationship changes.EducationWhat is your highest education level completed?Choose Highest Education Level CompletedHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrimary Life FocusWhat is your primary life focus area? Please elaborate.E.g.: occupation, retirement, studies, familyHow long has it been your primary life focus?Are you satisfied? Yes No In what ways are you dissatisfied?SexualitySexuality includes various components (behavior, orientation, identity, and history).Please share any relevant information:Compulsive Behaviors or SubstancesAre you concerned about any compulsive, addictive behaviors, or substance (eating, shopping, sexual behavior, cleanliness, repetitive actions, working, etc.)? Yes No Please elaborate.Self CareWhat resources (internal and external) do you use when feeling overwhelmed?Which individuals do you most frequently reach out to for social and emotional support?SpiritualityHow important is spirituality in your life?Choose ImportanceVery ImportantImportantSomewhat ImportantNot ImportantIf spirituality is a part of your life, in what way? Do you have regular spiritual practices? Please elaborate.AdditionalAnything else you want Dr. Julie to know? Informed Consent Form for Expert 1:1 ConsultationI voluntarily consent to an Expert 1:1 Consultation with Dr. Julie Lopez, Human Systems Expert. Through the process of the Expert 1:1 Consultation, I understand, that as I am working toward optimizing, balancing and improving my life experience, I may experience intense feelings as a part of this process, some of which may be painful. I also understand that when I make changes in myself, I may experience changes in other areas of my life (i.e. family, work, and social life may be affected). Every change potentially has both positive and negative effects. I also understand that by electing to participate in Dr. Julie’s Expert 1:1 Consultation, I have the opportunity to select a scientifically advanced intervention of an intensive customized nature (an “intensive”). Dr. Julie will assist with all follow-up integration needs and make appropriate therapeutic referrals if necessary. However, ultimately, due to the short-term nature of the intensive, I understand and agree that Dr. Lopez will not be responsible for any therapeutic needs that may be exposed in our work, and will not become my therapist at any time during the intensives since that service is not part of a Consultation package. I am aware that I am an active participant in my wellbeing, and I share the responsibility for the integration process to follow the intensive. Because of the nature of the work, I understand Dr. Julie will not be providing diagnostic codes nor procedural codes. This means the Consultation will not be covered by insurance, and I will be responsible in full for the Expert 1:1 Consultation payment. I understand that I can contact the nearest public emergency mental health service if needed. This form has been explained to me, and any questions I had have been answered. My signature below confirms that I fully understand the information set out above, including the limits of an Expert 1:1 Consultation and what will be required of me for successful outcomes, as well as my responsibility for payment for the Expert 1:1 Consultation, and with that understanding, my signature below indicates my choice to engage in an Expert 1:1 Consultation. Signature of Client*Name of Witness*Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
