ATHLETE/PERFORMER INTAKE INFORMATION

This form is to be completed by the athlete working with Dr. Lindsey. Take some time to think through your responses. Be sure to provide your thoughts and feelings on your strengths and weaknesses, rather than those of your parents, teammates, or coaches. This will help you prepare for your first session with Dr. Lindsey and enable us to hit the ground running.
Name:*
Preferred Pronouns:
D.O.B:*

MonthDayYear
Street Address, City, State, Zip Code*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number, (XXX-XXX-XXXX)*
Email Address:*

Reason for seeking services
Please explain why you are seeking to develop your mental skills through sport psychology.*
If someone else recommended this, what do you believe is their reason for suggesting you work with a sport psychologist?
What do you believe is holding you back from achieving your full performance potential?*
What do you hope to accomplish with mental skills training? What are your goals (short-term and long-term)?*

Performance History
Have you previously worked with a sport psychologist (mental performance specialist)?*

YesNoOther
If yes, please check all that apply:

IndividiuallyTeamWorkshopOne-time sessionOther
Describe your current sport/performance involvement.*

	YES	NO
Self-harm
Threatened suicide
Attempted suicide
Hospitalization in a psychiatric facility
Participation in psychotherapy

Reason for seeking services