Tranquil Horizon BehavHealth Consultants

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Intake Form

By filling out the form below, you will take the first step in focused enhanced chronic health management, reducing burnout, stress and implementing integrated behavioral health strategies.

Start Your Journey

Take the first step towards managing your chronic conditions, reducing burnout, stress and behavioral health by completing the membership form below. Join our community of like-minded professionals committed to making a difference in healthcare.

Personalized Support

Start here by answering the following questions to the best of your abilities. This information is held to the same standards of confidentiality as our sessions.

Full Name *

Home Address *

City, State, Zip code: *

Phone *

Email address | May we email you?* *NOTE: Emails may not be confidential. Yes / No *

Birth date: *

Age *

Marital status: (Single, Partnered, Married, Separated, Divorced, Widowed) *

Home phone: May we leave a message? Yes / No *

Referred by: (if none, type N/A) *

Are you currently receiving psychological services, professional counseling or coaching, psychiatric services, or any other mental health services? Yes / No *

Have you had any mental health services in the past? Yes / No *

Are you currently taking any psychiatric prescription medication? Yes / No *

Have you been prescribed psychiatric prescription medication in the past? Yes / No If yes, please list: *

How would you describe your physical health at the present time? (Poor, Unsatisfactory, Satisfactory, Good, Very good) *

Please list any persistent physical symptoms or health concerns (e.g., chronic pain, headaches, hypertension, diabetes, thyroid dysfunction, etc.): *

Are you on any medication for physical/medical issues? Yes / No If yes, please list: *

Are you having any problems with your quality of sleep? Yes / No *

If yes, check those that apply: Sleep too much, Sleep too little, Poor quality, Disturbing dreams, Other:

How many times per week do you exercise? (days / minutes / hours) *

Are there any changes or difficulties with your eating habits? Yes / No *

Name of parent or guardian (if minor):

If yes, choose those that apply: Eating less, Eating more, Bingeing, Restricting, Other: *

Have you experienced a weight change in the last two months? Yes / No If yes, describe: *

Do you consume alcohol regularly? Yes / No *

In one month, how many times do you have four or more drinks in a 24-hour period? *

How often do you engage in recreational drug use? Daily, Weekly, Monthly, Rarely, Never *

Have you felt depressed recently? Yes / No If yes, for how long? *

Have you had any suicidal thoughts recently? Yes / No *

If yes, how often? (Frequently, Sometimes, Rarely) *

Have you ever had suicidal thoughts in the past? Yes / No If yes, how long ago? *

Have you ever had suicidal thoughts in the past? Yes / No If yes, how long ago? *

How often did you have these thoughts? Frequently, Sometimes, Rarely

Are you currently in a romantic relationship? Yes / No If yes, how long have you been in this relationship? *

On a scale from 1 to 10 (10 being great, 1 being poor), how would you rate the quality of your relationship? Enter N/A if needed *

In the last year, have you experienced any major life changes (employment, relocation, relationship, illness, loss of loved one, etc.)? Describe. *

Check off the issues below that apply to you: *

Extreme depressed mood
Mood swings
Extreme anxiety
Panic attacks
Phobias
Sleep disturbance
Hallucinations
Memory problems
Body complaints
Alcohol/substance abuse
Eating disorder
Repetitive thoughts
Anxiety
Time loss
Repetitive behaviors
Homicidal thoughts
Indecision
Suicide attempts
Trouble planning
Lack of focus
Difficulty with relationships
Confusion
Anger issues

Occupational Information Are you currently employed? Yes / No *

If yes, who is your employer? *

What is your position? *

Are you happy in your current position? Yes / No *

Are you fulfilled in your current position? Yes / No *

New field *

Number of children: Ages: *

Does your work make you stressed? Yes / No If yes, what are your work-related stressors? *

Religious/Spiritual Information Do you practice or observe a religion? Yes / No If yes, what is your faith? *

If no, do you consider yourself to be spiritual? Yes / No

New field *

Cell/other: May we leave a message? Yes / No *

Family Mental Health History Please provide information about your family history. Choose from below. *

Depression
Anxiety Disorders
Bipolar Disorder
Panic Attacks
Alcohol Abuse
Drug Abuse
Eating Disorder
Learning Disability
Trauma
Domestic Violence
Obesity
OCD
Schizophrenia

For the selected, If yes, please indicate the family member/relationship affected. *

List your strengths. *

List areas you would like to develop or improve. *

What do you like most about yourself? *

What are some ways you cope with life obstacles and stress? *

What are your goals for health psychology coaching ? What would you like to accomplish during your sessions? *

Is there anything else you would like to share? *

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Ready to take the next step in improving your well being after your free consultation?

Make a payment prior to your appointment.

3 Month Membership at $185 per month (Save)

Month to Month Membership $225.00

Our Mission & Vision

Specialties

Testimonials

How We Can Help

Membership Options

Contact

Hours

Monday - Thursday: 10 am - 7 pm

Friday: 10am - 4pm

In some instances, we offer earlier or later appointments.

Saturday - Sunday: Closed

Our Location

Serving all of Texas

Virtual Office

In/Outbound mail:

1530 Sun City Blvd
Ste 120 #547
Georgetown, TX 78633

512-572-2124

Virtual behavioral health support for chronic illness and emotional wellness.

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