Consultation Application

Application Form

Dr. van der Kolk is not accepting new patients at this time, but please feel free to submit the form below to be placed on a waitlist for a one-time consult.

First Name

Last Name

Phone #

Age

City, State, Country

How long have you been living in your current home?

What specific issues would you like help with?

Who do you live with?

Do you have a partner?

Do you have children & how old? What is your relationship like with them?

Do you have parents? What's is your relationship with them?

What is your educational background?

What currently gives you satisfaction in your life?

Who is there for you?

Who do you take care of?

What do you do for a living? Give some details. How satisfying?

What are the 2 or 3 most relevant issues discussed in The Body Keeps the Score that makes you reach out for a consultation?

Describe your family background

List any professional or leisure interests

How many hours do you watch television?

Do you play a music instrument, sing with other people, dance with other people? Do you practice yoga? Meditation? Share how often each.

What do you consider to be your strengths?

What has been successful in your life and what has not been successful?

List any medical conditions

List current and past medication

List any prior therapy treatment and how long

List prior hospitalization and how long

What is your preferred method of contact?

Phone Call

Text

Mail

Check all that apply.

Consultation

Application Form

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