Podcast Consult Offering with Stacey Uhrig
Stacey Uhrig
Podcast Consult Offering
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Time Zone
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(GMT-12:00) International Date Line West
(GMT-11:00) American Samoa
(GMT-11:00) Midway Island
(GMT-10:00) Hawaii
(GMT-09:00) Alaska
(GMT-08:00) Pacific Time (US & Canada)
(GMT-08:00) Tijuana
(GMT-07:00) Arizona
(GMT-07:00) Mazatlan
(GMT-07:00) Mountain Time (US & Canada)
(GMT-06:00) Central America
(GMT-06:00) Central Time (US & Canada)
(GMT-06:00) Chihuahua
(GMT-06:00) Guadalajara
(GMT-06:00) Mexico City
(GMT-06:00) Monterrey
(GMT-06:00) Saskatchewan
(GMT-05:00) Bogota
(GMT-05:00) Eastern Time (US & Canada)
(GMT-05:00) Indiana (East)
(GMT-05:00) Lima
(GMT-05:00) Quito
(GMT-04:00) Atlantic Time (Canada)
(GMT-04:00) Caracas
(GMT-04:00) Georgetown
(GMT-04:00) La Paz
(GMT-04:00) Puerto Rico
(GMT-04:00) Santiago
(GMT-03:30) Newfoundland
(GMT-03:00) Brasilia
(GMT-03:00) Buenos Aires
(GMT-03:00) Montevideo
(GMT-02:00) Greenland
(GMT-02:00) Mid-Atlantic
(GMT-01:00) Azores
(GMT-01:00) Cape Verde Is.
(GMT+00:00) Edinburgh
(GMT+00:00) Lisbon
(GMT+00:00) London
(GMT+00:00) Monrovia
(GMT+00:00) UTC
(GMT+01:00) Amsterdam
(GMT+01:00) Belgrade
(GMT+01:00) Berlin
(GMT+01:00) Bern
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(GMT+01:00) Brussels
(GMT+01:00) Budapest
(GMT+01:00) Casablanca
(GMT+01:00) Copenhagen
(GMT+01:00) Dublin
(GMT+01:00) Ljubljana
(GMT+01:00) Madrid
(GMT+01:00) Paris
(GMT+01:00) Prague
(GMT+01:00) Rome
(GMT+01:00) Sarajevo
(GMT+01:00) Skopje
(GMT+01:00) Stockholm
(GMT+01:00) Vienna
(GMT+01:00) Warsaw
(GMT+01:00) West Central Africa
(GMT+01:00) Zagreb
(GMT+01:00) Zurich
(GMT+02:00) Athens
(GMT+02:00) Bucharest
(GMT+02:00) Cairo
(GMT+02:00) Harare
(GMT+02:00) Helsinki
(GMT+02:00) Jerusalem
(GMT+02:00) Kaliningrad
(GMT+02:00) Kyiv
(GMT+02:00) Pretoria
(GMT+02:00) Riga
(GMT+02:00) Sofia
(GMT+02:00) Tallinn
(GMT+02:00) Vilnius
(GMT+03:00) Baghdad
(GMT+03:00) Istanbul
(GMT+03:00) Kuwait
(GMT+03:00) Minsk
(GMT+03:00) Moscow
(GMT+03:00) Nairobi
(GMT+03:00) Riyadh
(GMT+03:00) St. Petersburg
(GMT+03:00) Volgograd
(GMT+03:30) Tehran
(GMT+04:00) Abu Dhabi
(GMT+04:00) Baku
(GMT+04:00) Muscat
(GMT+04:00) Samara
(GMT+04:00) Tbilisi
(GMT+04:00) Yerevan
(GMT+04:30) Kabul
(GMT+05:00) Ekaterinburg
(GMT+05:00) Islamabad
(GMT+05:00) Karachi
(GMT+05:00) Tashkent
(GMT+05:30) Chennai
(GMT+05:30) Kolkata
(GMT+05:30) Mumbai
(GMT+05:30) New Delhi
(GMT+05:30) Sri Jayawardenepura
(GMT+05:45) Kathmandu
(GMT+06:00) Almaty
(GMT+06:00) Astana
(GMT+06:00) Dhaka
(GMT+06:00) Urumqi
(GMT+06:30) Rangoon
(GMT+07:00) Bangkok
(GMT+07:00) Hanoi
(GMT+07:00) Jakarta
(GMT+07:00) Krasnoyarsk
(GMT+07:00) Novosibirsk
(GMT+08:00) Beijing
(GMT+08:00) Chongqing
(GMT+08:00) Hong Kong
(GMT+08:00) Irkutsk
(GMT+08:00) Kuala Lumpur
(GMT+08:00) Perth
(GMT+08:00) Singapore
(GMT+08:00) Taipei
(GMT+08:00) Ulaanbaatar
(GMT+09:00) Osaka
(GMT+09:00) Sapporo
(GMT+09:00) Seoul
(GMT+09:00) Tokyo
(GMT+09:00) Yakutsk
(GMT+09:30) Adelaide
(GMT+09:30) Darwin
(GMT+10:00) Brisbane
(GMT+10:00) Canberra
(GMT+10:00) Guam
(GMT+10:00) Hobart
(GMT+10:00) Melbourne
(GMT+10:00) Port Moresby
(GMT+10:00) Sydney
(GMT+10:00) Vladivostok
(GMT+11:00) Magadan
(GMT+11:00) New Caledonia
(GMT+11:00) Solomon Is.
(GMT+11:00) Srednekolymsk
(GMT+12:00) Auckland
(GMT+12:00) Fiji
(GMT+12:00) Kamchatka
(GMT+12:00) Marshall Is.
(GMT+12:00) Wellington
(GMT+12:45) Chatham Is.
(GMT+13:00) Nuku'alofa
(GMT+13:00) Samoa
(GMT+13:00) Tokelau Is.
Location Information
Address Line 1
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Address Line 2
Country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
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Curaçao
Cyprus
Czechia
Denmark
Djibouti
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El Salvador
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Ethiopia
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Faroe Islands
Fiji
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French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
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Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
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Jordan
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Kenya
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Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
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Lao People's Democratic Republic
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Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
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Netherlands
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Nicaragua
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Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
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Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
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Singapore
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Slovakia
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Solomon Islands
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South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
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Sudan
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Taiwan
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Tanzania
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United States
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Additional Information
Personal Data
What name do you prefer to go by
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What pronouns do you use? (e.g., she/her, he/him, they/them) or you can specify 'Prefer not to say' if you'd rather not share.
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Do you have any accessibility needs that would help you fully participate in our sessions? (e.g., physical accommodations, visual or auditory needs)
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Address
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Phone Number
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Emergency Contact
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Did you join your family by way of adoption, kinship, or guardianship?
Yes
No
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If yes, at what age where you adopted? Feel free to add in any details you are comfortable with.
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Your Relationahip Status
Single
In Partnership
Married
Divorced / Separated
Widowed
Other
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Number of Children you have (if any) - list ages if you'd like
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Parents Marital Status
Single
Married
Divorced / Separated
One or more parent deceased
Never Married
Other
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Number of siblings you have (list ages if you are comfortable)
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Occupation
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Medical
Do you have a history of autoimmune / chronic pain / chronic illness? If so, please select any or all that apply.
Addison disease
Dermatomyositis
Graves disease
Hashimoto thyroiditis
Inflammatory bowel disease (Crohn disease, ulcerative colitis)
Multiple sclerosis
Myasthenia gravis
Rheumatoid arthritis
Sjögren syndrome
Systemic lupus erythematosus (lupus)
Type I diabetes
Other
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If you have a significant medical history not listed above, please feel free to describe below.
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Backstory
How did you find me?
Referral - Friend
Referral - Family
Referral - Other practitioner
Instagram
Facebook
Networking Group
Other
Podcast
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Please list specific referral (for example if family / friend please list name)
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What made you schedule this call? What are you struggling with?
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What have you tried so far to overcome this challenge?
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Please select any or all that apply (occuring before the age of 18)...
Did you feel unseen or unheard at home?
Did you have a parent or caretaker who denied your reality?
Did you have a parent or caretaker who did not model appropriate boundaries?
Were you told that you can't or shouldn't feel certain emotions?
Did you live with someone who could not regulate their emotions?
Have a parent more focused on outward personal appearances and family appearances versus being authentic to life at home?
Did a parent or caretaker swear at you, insult you, or put you down on a frequent basis.
Was it common for a parent or caretaker humiliate you or act in a way that made you afraid that you might be physically hurt?
Did you find yourself in situations in which a parent or family member didn’t look out for you, feel close to your, or support you?
Did a parent or caretaker push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured?
Did you often or very often feel that no one in your family loved you or thought you were important or special?
Were your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Did you find yourself in a situations in which you didn’t have enough to eat, had to wear dirty clothes and had no one to protect you?
Was a biological parent ever lost to you through death, divorce, abandonment, or other reasons?
Was a parent or caretaker: often or very often pushed, grabbed, slapped, or had something thrown at her/him?
Was a parent or caretaker sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?
Did you experience being repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you witness someone else being repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Were you asked to keep secrets by a parent or caretaker that made you feel uncomfortable?
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Please share any additional information you feel would be useful for me to know prior to our meeting.
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