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Intake Medical History

Please give details of any diagnosed medical conditions:

What is your daily use/consumption of? Alcohol: Water: Cigarettes/Tobacco: Tea/Coffee:

How many of these do you have? Mercury fillings: Crowns: Root canals:

Are you avoiding any foods? Please list them if so:

Please list your main physical symptoms:

Please list your main emotional issues:

Please detail any events or experiences that brought on these symptoms:

Do any run in the family? If so, which ones?

Are you currently pregnant or trying?

Life History

If you are happy to, please summarize the headline events or times that were emotionally stressful or might possibly be unresolved. I have written in clues to the kind of issue that might come up at each life stage. A headline overview is all that is needed, we can discuss the finer details in our session if appropriate.

Conception to birth (Planned? Wanted? Parents married? Right sex? Mom previous miscarriages? Mom supported and happy?)

Birth itself (Forceps? C-Section? Premature? Cord around neck? Induced? Long labour? Fetal stress?)

Post Birth Period (Breast fed? Mom PND? Incubated? Any separation from mother, at all? Early development?)

Early Childhood (Sibling issues? Good health? Strong family unit? Move house? Babysitters or nannies? Bed wetting?)

Relationship with Parents (Absent father or mom? Happy family? Loved? Received all the attention you needed?)

Schooling (Bullied? Teachers ok? Good friends? Did well academically?)

Puberty and adolescence (Early or late puberty? First relationships and sexual experience? Unrequited love? Regrets?)

Work issues (Bullying? Over-work? Stress? Financial issues? Unfulfillment?)

Relationships - friends and family (Aunties, uncles, grandparents, friends etc ? Difficult dynamics? Disapproval? Judgement?)

Relationships - partner (Stagnancy? Intimacy issues? Separate interests? Overwork? Enough time for each other?)

Adulthood generally (Any miscellaneous issues not covered above, accidents? Traumas?)

Bereavements / traumas (Losses that still feel raw now? Abortion or miscarriage?)

Areas of Life Rating

This rating activity is a quick, intuitive exercise. Close your eyes, take three slow deep breaths, then open your eyes and rate each area with the first number that comes to mind.

(Rate all 9 areas from 1 to 10: 1 = completely unsatisfied; 10 = completely satisfied)

Business/Career/Work:

Family (parents, siblings, aunts & uncles & 1st cousins):

Health:

Intimate Relationships (partner only–can have intimacy without sex):

Money:

Self-Love (how you speak to and show up for yourself–personal development):

Self-Expression (how you show/present to others–social relationships/hobbies):

Sex (can have sex without intimacy):

Spirituality:

What, in particular, do you hope to gain from these sessions?

Client Consent and Service Agreement Page

I acknowledge completion of the client intake process with Agape Therapeutic Health Services. By agreeing with this document, I confirm that I am at least 18 years of age and of sound mind and possess the mental capacity to consent to services. I voluntarily choose to take part in intuitive bodywork, energy medicine, and/or virtual holistic coaching services provided by Kent Smith and Agape Therapeutic Health Services for personal development and self-improvement purposes.

Nature of Services and Understanding

I understand that these services are complementary health approaches that may include dialogue, visual assessment, touch, and movement techniques designed to support the body's natural healing processes. These methods may incorporate energy-based perspectives on health and wellness.
These services are supplementary health aids and do not replace primary medical or mental health care. Any information provided is educational and does not make up medical diagnosis or treatment.

Client Responsibilities and Rights

I confirm that all my health information given is accurate and complete and I will promptly inform Kent Smith of any changes.
I understand that my personal information is confidential and requires my explicit written consent for release to any third party.
I may withdraw my consent and end a session if I am uncomfortable with the process. Kent Smith reserves the right to end sessions immediately for inappropriate behavior, with the full session fee remaining due.

Consent and Release

I assume full responsibility for receiving these services and release Kent Smith and Agape Therapeutic Health Services from any current or future claims or liabilities made by myself or my representatives.
By signing this agreement, I grant Kent Smith and Agape Therapeutic Health Services permission to collect and use my intake information under this document and the complete website Disclaimer (Terms of Service) and Privacy Policy, regardless of whether I have reviewed these policies.

Data Privacy and Confidentiality

I understand that Kent Smith and Agape Therapeutic Health Services will handle my confidential information according to applicable privacy laws and their privacy policy and will protect it with security measures.

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Signed by Kent Smith
Signed On: June 24, 2025

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February 27, 2020 11:18 pm PDT

Client Intake and Informed Consent Package Uploaded by Kent Smith - kent@agapetherapeutic.com IP 24.80.196.177