Splankna Therapy New Client Form Please enable JavaScript in your browser to complete this form.CLIENT INFORMATIONName *FirstLastEmail *Main Phone Number *Secondary Phone NumberAge *Gender *FemaleMaleReligious Preference *Who will you be seeing for your Splankna session? *Cynthia Hofmann-CoaleCynthia Hofmann-CoaleAbby ThomasNicole BroderickMARITAL HISTORYMarital Status *Never MarriedMarriedSeparatedDivorcedWidowed1st Marriage:Date(s):Spouse:Children:Who has custody of your minor children?2nd Marriage:Date(s):Spouse:Children:Who has custody of your minor children?Other Marriages/Children:List any other marriages and/or children:HEALTH INFORMATIONHave you ever considered suicide? *YesNoHave you ever attempted suicide? *YesNoDo you suffer from:MigrainesEpilepsyVertigoCheck any of the following which are currently causing you difficulty:AngerHealthMy PastCareer ChoicesDatingSelf-conceptFoodAnxietySexual ProblemMarriageReligionNightmaresPanic AttacksConcentrationFinancesPhobiaGriefWorkAssertivenessSuicidal ThoughtsEnergyAbuseHeadachesParentingAddictionParentsSleep TroubleViolenceDivorceHearing VoicesGuiltSadnessSelf-ControlDepressionStep-familyIn-lawsCuttingObsessivenessLegal IssuesHopelessnessWhat is/was your Father’s main character weakness?What is/was your Mother's main character weakness?What is your birth order? (i.e. oldest, youngest, of how many, etc.) *How will you be different if this therapy is successful?CLIENT CONSENTPlease check below to indicate that you have read and understand the Statement of Confidentiality below: * I understand and agree to the below Statement of Confidentiality. *Statement Of Confidentiality: The Client-Therapist relationship offers confidentiality in so far as allowed by the laws of the State of Pennsylvania. Under certain conditions, the right to confidentiality is necessarily violated. Those conditions include the potential for suicide or homicide on the part of the client. Likewise, when there is reason to suspect that physical or sexual abuse has occurred to a child or an elderly person, the therapist is required by law to report the situation to the Department of Human Services, division of Child Protective Services.Client Informed Consent and Disclosure Statement *Please click HERE to read our Client Informed Consent and Disclosure Statement. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Consent and Disclosure Statement.PhoneSubmit