Trauma Coaching Intake

Smalley Institute

Trauma Coaching Intake

Thank you for taking this step toward healing. Please complete this form thoughtfully—your answers help us create a personalized plan for your coaching session.

Your progress Section 1 of 7

Let's Start with the Basics

A little about you so we can connect.

First Name *

Last Name *

Email Address *

Phone Number *

Age

How did you hear about trauma coaching with the Smalley Institute?

What Brings You Here

Help us understand what you're hoping to work through.

What type(s) of experiences would you like support with? (Select all that apply)

Childhood trauma or abuse Betrayal or infidelity (partner, friend, family member) Loss or grief Emotional or psychological abuse Physical abuse Sexual abuse or assault Neglect (emotional or physical) Spiritual or religious trauma Medical trauma or serious illness Accident, natural disaster, or witnessing violence Other

In a few sentences, briefly describe what you're hoping to work through. (Share only what feels comfortable—we'll go deeper together in our session)

When did this experience (or these experiences) occur?

Childhood (before age 18) Adulthood (18+) Both childhood and adulthood Recent (within the past year) Ongoing or current situation

How It's Affecting You Now

Understanding your current experience helps us know where to focus.

Which of these do you experience regularly? (Select all that apply)

Intrusive thoughts or memories that pop up uninvited Flashbacks (feeling like you're reliving the experience) Nightmares or difficulty sleeping Anxiety, feeling on edge, or hypervigilance Feeling numb, disconnected, or emotionally flat Difficulty concentrating or "brain fog" Avoiding people, places, or things that remind you Irritability or anger that feels disproportionate Persistent shame or guilt Difficulty trusting others or yourself Physical symptoms (tension, stomach issues, headaches) Relationship difficulties

On a typical day, how would you rate your overall distress level?

Manageable Overwhelming

Are you aware of specific triggers that tend to bring up difficult emotions or reactions? (If so, briefly describe)

Your Safety & Wellbeing

These questions help us ensure we're providing the right level of support.

A Note About These Questions

Your safety matters deeply to us. Please answer honestly—there are no wrong answers, and your responses help us support you appropriately. If your situation requires more specialized care, we'll help connect you with the right resources.

Are you currently in a physically or emotionally safe living situation? *

Yes, I feel safe Somewhat—there are some concerns No, I don't feel safe I'd prefer to discuss this in our session

In the past month, have you had any thoughts of harming yourself? *

No Fleeting thoughts, but no plan or intent Yes, with some frequency Yes, and I've thought about how I might do it

If you're in crisis: Please reach out to the 988 Suicide & Crisis Lifeline (call or text 988) or contact emergency services. You don't have to face this alone.

Are you currently using alcohol or substances to cope with difficult feelings?

No Occasionally Regularly, and it's become a concern I'm in recovery

Are you currently working with a therapist, counselor, or psychiatrist?

Yes, I have a therapist or counselor Yes, I see a psychiatrist for medication Yes, both therapy and psychiatry No, but I have in the past No, I haven't worked with a mental health professional

Have you ever been diagnosed with any mental health conditions? (e.g., PTSD, anxiety, depression, etc.)

Your Existing Strengths & Resources

You already have wisdom and tools. Let's build on what's working.

What do you already do to help yourself feel calmer or more grounded? (Select all that apply)

Deep breathing or breathwork Prayer or meditation Exercise or physical movement Journaling or writing Talking to a trusted friend or family member Spending time in nature Music, art, or creative expression Grounding techniques (5 senses, etc.) Scripture or spiritual reading Working with a professional I'm not sure what helps—I want to learn

What has been most helpful to you in the past when dealing with difficult emotions?

Who are the safe, supportive people in your life right now? (Could be family, friends, church community, etc.)

How familiar are you with trauma and nervous system concepts (like "fight, flight, freeze" or "window of tolerance")?

Very familiar—I've studied this or been in therapy Somewhat familiar—I've read or heard about these A little—I know the basics Not really familiar—this is new to me

Your Goals & Spiritual Life

What does healing look like for you, and how does faith play a role?

What is your primary goal or hope for trauma coaching? *

What would you most like to gain from our coaching sessions? (Select your top 3)

Understanding why I react the way I do Practical tools to calm myself when triggered A safe space to talk through what happened Reducing flashbacks, nightmares, or intrusive thoughts Improving my relationships Feeling more present and less disconnected Spiritual healing or reconnecting with God Freedom from shame and guilt Hope that things can actually get better

How would you describe your faith or spiritual life?

I have an active Christian faith Faith is important to me, but my relationship with God feels complicated right now I'm exploring faith or returning after time away I consider myself spiritual but not religious Faith isn't a significant part of my life Other (please describe below)

How would you like faith or spirituality to be incorporated (or not incorporated) in our work together?

Has your trauma affected how you see God or your relationship with Him? (Optional)

Final Details

Almost done! Just a few more things to help us prepare for your session.

Is there anything else you want me to know before our session?

What is the best way to contact you with session details?

Email Phone call Text message

Understanding Trauma Coaching

Trauma coaching focuses on helping you develop awareness, coping skills, and grounding techniques to manage trauma responses in the present. While coaching can be powerful and supportive, it is not the same as licensed therapy or counseling. Michael Smalley is not a licensed mental health professional, and trauma coaching does not constitute medical or psychological treatment.

For complex trauma, PTSD, active crisis, or mental health diagnoses, working with a licensed therapist alongside coaching is often recommended. We're happy to help you find appropriate resources if needed.

I understand that trauma coaching is not therapy and that Michael Smalley is not a licensed mental health professional. *

Confidentiality

Your information will be kept confidential and used only to prepare for and support your coaching sessions. The only exceptions would be if you share information indicating risk of harm to yourself or others, which may require us to connect you with emergency resources.

I understand and agree to these confidentiality terms. *

Today's Date *

Thank You

Your intake form has been submitted. We'll review your information and be in touch soon to confirm your trauma coaching session. You've taken an important step toward healing.

Trauma Coaching Intake

Trauma Coaching Intake

Let's Start with the Basics

What Brings You Here

How It's Affecting You Now

Your Safety & Wellbeing

A Note About These Questions

Your Existing Strengths & Resources

Your Goals & Spiritual Life

Final Details

Understanding Trauma Coaching

Confidentiality

Thank You

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