Stacey Uhrig
1:1 Consultation
USD 75.00
Stacey Uhrig
Certified Coach & Trauma Specialist
75 Minutes
Personal Information
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Location Information
Time Zone
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Country
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Additional Information
Personal Data
What name do you prefer to go by
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Do you have any accessibility needs that would help you fully participate in our sessions? (e.g., physical accommodations, visual or auditory needs)
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Address
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Phone Number
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Emergency Contact
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Did you join your family by way of adoption, kinship, or guardianship?
Yes
No
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If yes, at what age where you adopted? Feel free to add in any details you are comfortable with.
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Your Relationahip Status
Single
In Partnership
Married
Divorced / Separated
Widowed
Other
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Number of Children you have (if any) - list ages if you'd like
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Parents Marital Status
Single
Married
Divorced / Separated
One or more parent deceased
Never Married
Other
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Number of siblings you have (list ages if you are comfortable)
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Occupation
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Medical
Do you have a history of autoimmune / chronic pain / chronic illness? If so, please select any or all that apply.
Addison disease
Dermatomyositis
Graves disease
Hashimoto thyroiditis
Inflammatory bowel disease (Crohn disease, ulcerative colitis)
Multiple sclerosis
Myasthenia gravis
Rheumatoid arthritis
Sjögren syndrome
Systemic lupus erythematosus (lupus)
Type I diabetes
Other
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If you have a significant medical history not listed above, please feel free to describe below.
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Backstory
How did you find me?
Referral - Friend
Referral - Family
Referral - Other practitioner
Instagram
Facebook
Networking Group
Other
Podcast
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Please list specific referral (for example if family / friend please list name)
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What made you schedule this call? What are you struggling with?
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What have you tried so far to overcome this challenge?
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Please select any or all that apply (occuring before the age of 18)...
Did you feel unseen or unheard at home?
Did you have a parent or caretaker who denied your reality?
Did you have a parent or caretaker who did not model appropriate boundaries?
Were you told that you can't or shouldn't feel certain emotions?
Did you live with someone who could not regulate their emotions?
Have a parent more focused on outward personal appearances and family appearances versus being authentic to life at home?
Did a parent or caretaker swear at you, insult you, or put you down on a frequent basis.
Was it common for a parent or caretaker humiliate you or act in a way that made you afraid that you might be physically hurt?
Did you find yourself in situations in which a parent or family member didn’t look out for you, feel close to your, or support you?
Did a parent or caretaker push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured?
Did you often or very often feel that no one in your family loved you or thought you were important or special?
Were your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Did you find yourself in a situations in which you didn’t have enough to eat, had to wear dirty clothes and had no one to protect you?
Was a biological parent ever lost to you through death, divorce, abandonment, or other reasons?
Was a parent or caretaker: often or very often pushed, grabbed, slapped, or had something thrown at her/him?
Was a parent or caretaker sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?
Did you experience being repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you witness someone else being repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Were you asked to keep secrets by a parent or caretaker that made you feel uncomfortable?
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Please share any additional information you feel would be useful for me to know prior to our meeting.
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