ABOUT
OUTSHINING TRAUMA
THE SCHOOL OF GROUNDED TRANSFORMATION
FULL CURRICULUM
BREAKING CYCLES
HEARTSPACE: WEEKLY PARTS WORK SANGHA
SELF-PACED COURSES
Chrysalis Full Course
Embodied Presence
Redefining Self-Love
Unstuck: How to Heal Every Part of You
1:1 WORK
BOOKS
DON'T TELL ME TO RELAX
THE MONKEY IS THE MESSENGER
AUDIOBOOK: THE MONKEY IS THE MESSENGER
AUDIOBOOK: OUTSHINING TRAUMA
MEDIA
RALPH ON INSIGHT TIMER APP
YOUTUBE CHANNEL
PODCAST APPEARANCES
STREAMING MEDITATIONS
PRESS
TESTIMONIALS
CONTACT
DONATE
Menu
RALPH DE LA ROSA, LCSW
Psychotherapist | Meditation Teacher | Author
ABOUT
OUTSHINING TRAUMA
THE SCHOOL OF GROUNDED TRANSFORMATION
FULL CURRICULUM
BREAKING CYCLES
HEARTSPACE: WEEKLY PARTS WORK SANGHA
SELF-PACED COURSES
Chrysalis Full Course
Embodied Presence
Redefining Self-Love
Unstuck: How to Heal Every Part of You
1:1 WORK
BOOKS
DON'T TELL ME TO RELAX
THE MONKEY IS THE MESSENGER
AUDIOBOOK: THE MONKEY IS THE MESSENGER
AUDIOBOOK: OUTSHINING TRAUMA
MEDIA
RALPH ON INSIGHT TIMER APP
YOUTUBE CHANNEL
PODCAST APPEARANCES
STREAMING MEDITATIONS
PRESS
TESTIMONIALS
CONTACT
DONATE
INTAKE FORM
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Preferred Gender Pronoun:
Emergency Contact (name, relationship, email address, and phone number):
*
Name and location of current employer:
*
What brings you to therapy or consulting at this time?
What are your goals for our work together?
FOR THERAPY CLIENTS ONLY:
Are you currently taking psychiatric medication? If so, please list name and dosage of medication.
If taking psychiatric medication, what is the name and phone number of your provider?
Do you drink alcohol?
Yes
No
If yes, about how many drinks per week?
Do you use recreational drugs?
Yes
No
If yes, what do you use and about how much per week?
Do you have suicidal thoughts?
Yes
No
Do you currently have a plan? If so, what is your plan?
Have you ever attempted suicide?
Yes
No
Do you have thoughts or urges to harm others?
Yes
No
If yes, do you currently have a plan to do this? If so, what is your plan?
Have you ever been hospitalized for psychiatric issue?
Yes
No
Is there a history of mental illness in your family?
Yes
No
If yes, please list family members, know diagnoses, and if this impacted you personally.
Do you currently feel safe where you are living?
Is there anything else you would like me to know?
Text Area
Thank you!