Client Intake Form | Mind Therapy with Brooke

Client Intake Form & Confidentiality Agreement

Before You Begin:

Brooke’s Mind Therapy provides private sessions to support personal healing, mindset shifts, and transformation.

⚠️ After-Session Care
Do not return directly to work or resume parenting responsibilities right after your session. Instead, allow yourself space to integrate by:

Journaling or practicing what you learned
Eating or light movement
Taking a nap or a walk
Watching something relaxing
Sleeping (this is most optimal after a session)

Personal Information

First name

Last name

Birthday

Month

Day

Year

Age

Phone

Address

Emergency Contact

Name

Relationship

Phone Number:

Health & Background

How would you describe your current physical health?

Excellent

Good

Fair

Poor

Do you have any current medical conditions or diagnoses?

Are you currently taking any medications?

Yes

If yes, please list:

Have you ever worked with a therapist, coach, or healer before?

Yes

If yes, what type and what was your experience?

Current Concerns & Goals

What brought you here? What challenges are you facing right now?

What changes would you like to experience through Mind Therapy?

On a scale of 1–10, how motivated are you to make a change?

Confidentiality Agreement

Your privacy and trust are essential. This agreement explains how your personal information and what you share in sessions will be protected.

1. Confidentiality of Information

Everything shared in your sessions is confidential.
Your intake form, session notes, and communication with Brooke will not be shared without your consent.
Records are securely kept and used only to support your personal work in Mind Therapy.

2. Limits of Confidentiality

Confidentiality may only be broken if:

You provide written consent to release specific information.
Disclosure is required by law (e.g., subpoena, court order).
There is a clear and immediate risk of serious harm to yourself or others.
There is suspicion of child abuse, elder abuse, or abuse of vulnerable persons, which must be reported to authorities.

3. Privacy in Communication

Communication via phone, email, text, or online forms will be handled with care, but no system is 100% secure. By using these methods, you accept this risk.
Sensitive matters are best discussed in session.

4. Session Recordings and Notes

Sessions will not be recorded unless you give written permission.
If you consent to a recording, it will be shared only with you and not stored by Brooke beyond the agreed timeframe.
Notes are for Brooke’s reference only and remain private.

5. Boundaries of Service

Brooke is not a medical doctor or licensed medical professional.
Mind Therapy supports healing and transformation but does not replace medical or psychological treatment.
You are responsible for your own choices, actions, and results outside of sessions.

6. Client Responsibility

You agree to provide honest information in all forms and sessions.
You understand that your active participation is essential to your progress.

I have read and understood the Confidentiality Agreement. I agree to these terms.

Release Statement

I give my full consent to receiving sessions from Brooke (Brooke’s Mind Therapy) for the purposes outlined in this intake form and for any future goals or areas of focus that I may request.

I understand that the success of my sessions depends greatly on my own ability and willingness to create change in myself. I recognize that results depend on my level of participation and that Brooke cannot guarantee outcomes. I am aware, however, that Brooke will do everything possible to support my success, and I agree to participate fully in each session to the best of my ability.

I hereby release Brooke from any liability related to my participation in Mind Therapy.

I also understand that I have other options for addressing my specific concerns, and I have chosen Mind Therapy at this time. I have been advised that I am free to end any or all sessions at any time. I confirm that I have provided accurate background information as requested in this intake form.

If sessions are held in person and a therapeutic technique involves light touch, I understand that I will always be informed beforehand and my consent will be requested at the moment. If sessions are held online, there will be no physical touch, and this does not reduce the effectiveness of the process.

I have read and understood the Release Statement. I agree to these terms.

Scope of Work

You have the right to refuse any part of Brooke’s services and to seek support from another provider at any time. There are no refunds for services provided, and Brooke does not guarantee specific outcomes or results.

The scope of work is defined by the challenges and goals you shared during your FREE Discovery Call. If you identify a new, additional, or separate concern after your initial breakthrough, it will be treated as a new issue. In that case, we will begin again with a FREE Discovery Call to reassess and decide how to move forward.

I agree to the defined Scope of Work and understand the conditions described above.

Payment Terms

Payment is due prior to your appointment by credit card, Zelle, or other approved methods. Transaction fees may apply.

To secure your appointment, payment must be made within 24 hours.

Payment Options:

Zelle: Brooke Pollind — 760.415.5825
Venmo: @brookesmindtherapy
Credit Card: Pay over the phone, or I can send a link (3% processing fee applies)

Cancellation Policy

Your scheduled time is reserved exclusively for you. Please arrive on time (whether in-person or via Zoom) to receive the full benefit of your session. A minimum of 24-hour notice is required to cancel or reschedule, except in the case of an emergency. If you must cancel or reschedule due to an emergency, please notify Brooke as soon as possible.

If you do not attend your scheduled session and proper notice has not been provided, you will be responsible for the full session fee.

I have read and agree to the Fees & Payment terms and the Cancellation Policy outlined above.

Acknowledgment

By typing my full legal name below, I acknowledge that this serves as my digital signature. I confirm that I have read, understood, and agree to all the terms outlined in this form.

Full Name (Signature)

Date

Month

Day

Year

I agree that submitting this form digitally is acceptance of all terms and conditions listed herein.