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Clearpath Therapy Group
Developmental Intake
Confidential intake questionnaire
Before we begin — there are no right or wrong answers. This questionnaire helps Clearpath understand your experiences and prepare for a possible consultation or treatment. A clinician will review what you share.
This uses AI-assisted pattern recognition to organize your responses. It does not diagnose you or make clinical decisions.
Before We Begin
A few quick questions to provide helpful context.
Required fields are marked with *. All other fields are optional — share only what you're comfortable with.
Phase 1 — Memory Gateway
Q1-A
Think back as far as you can. How accessible are your early childhood memories?
A
Clear + vivid
Detailed, specific memories going back to a very young age.
B
Scattered / hazy
A few memories, but things feel fragmented or out of reach.
C
Mostly blank
Early childhood feels largely or entirely inaccessible before a certain age.
⚑ Clinician alert — routes to somatic checks
Phase 1 — Memory Gateway
Q1-A1
Approximately what age do your clearest memories start?
A
Before age 4
Likely developmentally typical — very early memory is common before age 4.
↳ Standard path
B
Age 4–9
This may be worth exploring with a clinician.
⚑ Moderate memory gap noted
C
Age 10 or older
Significant memory gap for a period where clear recall is expected.
⚑ Elevated memory gap — clinician alert
Phase 1 — Memory Gateway
That's okay — some people find that early memories aren't easily accessible. A clinician can work with that gently. We're going to ask a few different kinds of questions that don't rely on specific memories.
⚑ Dissociative Shield / Memory Gap flag — clinician alert. Routing to somatic checks. Q1-B skipped.
Phase 1 — Memory Gateway
Q1-B
For the memories you can access, what is their primary emotional tone?
Select All That Apply
A
Mostly happy / secure
Generally positive, warm, or neutral. I felt safe.
↳ Standard Sensitivity Path
B
Painful / lonely / heavy
Feelings of being misunderstood, isolated, anxious, or heavy emotional weight.
⚑ Early emotional distress — HSP evaluation
C
Fearful / abusive / chaotic
Direct fear, unpredictability, intimidation, or physical and emotional abuse.
⚑ High Trauma / Safety Alert — clinician review before session one
D
Mixed — it depended
Some memories feel safe or warm; others feel frightening, heavy, or painful. It wasn't consistent.
Thank you for sharing that. What you experienced took real courage to name. A Clearpath clinician will review your responses.
Q1-C
When thinking about those experiences — what primary forms did that take?
Select All That Apply
A
Verbal / emotional
Constant criticism, yelling, intimidation, or humiliation.
B
Physical
Physical punishment, hitting, rough handling, or bodily threat.
C
Neglect / abandonment
Being left unattended, physical needs unmet, or severe emotional abandonment.
D
Combination of multiple types
A pervasive mix of several or all of the above.
Q1-C1 — How frequently did these experiences occur?
A
Once or a few isolated times
B
Occasionally — happened but wasn't constant
C
Regularly — a recurring part of my childhood
⚑ Chronic abuse pattern
D
Constantly — it was the environment I grew up in
⚑ Pervasive / complex trauma — clinician priority
Optional — Is there anything else you'd like a clinician to know?
A Clearpath clinician will review your responses and may follow up about next steps.
Phase 1 — Memory Gateway
Q1-D
Looking back at your childhood, where did most of the difficulty come from?
Select All That Apply
A
People close to me
Experiences involving abuse, neglect, broken trust, or emotional boundary violations by caregivers, family, or peers.
⚑ Interpersonal ACE — highest physical health risk indicator per Caglayan et al. (2025)
B
Life circumstances
Accidents, serious illness, medical procedures, or events that had nothing to do with how people treated me.
⚑ Impersonal ACE — elevated health risk, lower relational impact than interpersonal
C
Both — difficulty from people AND from circumstances beyond anyone's control
D
Neither of these feels like the right description for my experience
Phase 1 complete. Moving to Phase 2 — Sensitivity Baseline.
Phase 2 — Sensitivity Baseline
Research shows some people are born with a more reactive nervous system — they feel things more deeply and are more affected by their environment. This is not a weakness. It is a biological difference that matters deeply for how healing happens.
Q2-A
Growing up, how would you describe your natural reaction to your environment compared to other kids?
A
I felt things deeply, became easily overwhelmed by chaotic environments, and quickly absorbed the emotional tension in the room.
↳ Orchid Profile / High Reactivity
B
I noticed intense environments and shifting moods, but I could usually adapt, roll with the punches, and keep going.
↳ Moderate Adaptive
C
I was largely unbothered by loud, chaotic environments or the emotional stress of the people around me.
↳ Dandelion Profile / Low Reactivity
Phase 2 — Sensitivity Baseline
Q2-A2
When dealing with relational conflict or high-pressure situations, how do you process the aftermath emotionally?
Select One
A
I process it quickly and let it go without lingering stress
I move on without much mental replay.
B
It takes some time to decompress, but normal rhythms return shortly
I need a little space but I find my footing.
C
I deeply analyze and replay interactions — prolonged cognitive and emotional loops
My mind keeps returning to it even when I try to move on.
⚑ Deep processing / rumination — Orchid indicator + Caglayan et al. risk flag
D
I completely disconnect, shut down, or avoid triggers to stay functional
Disconnection is how I keep moving.
⚑ Avoidant processing / masked presentation
Phase 2 — Sensitivity Baseline
Q2-B
If you have siblings, how would you describe your sensitivity compared to theirs growing up?
Think about how you each reacted to stress, emotion, or difficult situations in your household.
A
I was noticeably more sensitive than my siblings
Things affected me more deeply — I felt things they seemed to brush off.
↳ Orchid confirmation — same environment, higher absorption
B
I was about the same as my siblings
We seemed to react to things in similar ways.
C
I was actually less sensitive than my siblings
They seemed to feel things more intensely than I did.
D
I'm an only child — or didn't grow up with siblings to compare
E
I'm not sure — it's hard to say
Phase 2 — Sensitivity Baseline
Q2-C
Thinking about how sensitive or reactive you are — does it feel like something you were born with, or something that developed over time?
A
This feels like how I've always been wired
It feels innate — just part of how I came into the world.
↳ Innate orchid — routes to Orchid Index
B
I think I became this way in response to my experiences
I wasn't always like this — something shifted over time.
I'm not sure what I was like before that happened.
⚑ Masked orchid — possible suppressed sensitivity — clinician note
Phase 2 — The Orchid Index
Q2-D
When you encountered high demand, criticism, or stress growing up — whether at home, school, or in your activities — how did you most frequently cope?
Select All That Apply
A
Internalized shielding
Tried to be "good," quiet, or perfect to avoid making waves.
↳ Adult: perfectionism, anxiety, fawn
B
Withdrawal and isolation
Retreated into my room, books, or imagination — or shut down and went numb.
↳ Adult: avoidance, dissociation, depression
C
External defense
Pushed back, argued, acted out, or used anger and defiance.
↳ Adult: externalizing, relationship conflict
D
Early self-soothing / numbing
Sought physical comforts, food, repetitive behaviors, or early substances.
⚑ Early numbing behavior — clinician note
E
External support
I was able to talk to a safe adult, parent, or mentor who helped me regulate.
✓ Protective factor
Phase 3 — Environmental Mismatch
Q3-A
How did the adults in your household handle the different personalities or needs of the children?
Select All That Apply
A
The uniform rulebook
A strict, one-size-fits-all standard. Individual differences were not accommodated.
⚑ Environmental mismatch risk
B
Individualized attunement
Adults generally tried to adapt parenting to fit each child's unique temperament.
✓ Protective factor
C
Unpredictable / chaotic
Rules changed constantly based on the adults' stress levels or moods.
⚑ Chaotic home environment — elevated trauma risk
D
Absent or non-traditional household
Raised by a single parent, grandparents, extended family, foster carers, or non-traditional setting.
↳ Clinician will explore structure in session one
Phase 3 — Environmental Mismatch
Q3-A-B
From the outside — what would a parent, teacher, or caregiver have seen when you were overwhelmed as a child or teenager?
Select All That Apply
Think about what your behavior looked like to others, not what was happening inside you.
A
Acted out
Yelled, misbehaved, or pushed back against adults.
B
Shut down
Withdrew, hid, went quiet, or disappeared into yourself.
C
Expressed it
Shared feelings verbally or through creative outlets like art, music, or writing.
✓ Healthy expressive coping
D
Sought comfort
Looked for physical soothing, food, screens, or anything that made the feeling quieter.
E
Tried to fix it
Became the peacemaker, caretaker, or "good one" to reduce tension around you.
⚑ Fawn response pattern
Phase 3 — Environmental Mismatch
Q3-A-C
When you behaved in that way, how did the adults — parents, teachers, or caregivers — typically respond?
A
Ignored or overlooked
My withdrawal or behavior went completely unnoticed or unaddressed.
⚑ Invisible distress — attunement failure
B
Punished or scolded
Criticized, shamed, or met with strict anger for acting out or showing big emotions.
⚑ Shame response conditioned
C
Minimally accommodated
They let me be, but didn't check in or help me process why I was overwhelmed.
⚑ Partial attunement
D
Attuned and supportive
They noticed, offered a safe space, validated, and helped me through the emotional state.
✓ Secure attachment — protective factor
Phase 4 — Compensatory Trajectory
By adulthood, our nervous systems have developed strategies — often unconscious — to manage the stress load we carry. These patterns are not character flaws. They are adaptations.
Q3-A-B-A
What primary tools did your nervous system use to cope with overwhelming stress or chronic internal pressure?
Select All That Apply
A
Internalizing
Chronic anxiety, perfectionism, overworking, relentless self-criticism, or silently shutting down.
B
Substance use / numbing
Turning regularly to alcohol, drugs, excessive gaming, social media, or other numbing behaviors.
⚑ Substance use / behavioral addiction flag
C
Externalizing
Outbursts of frustration, defensive pushing away of others, impulsive decisions, or rebellious risk-taking.
D
Body-based symptoms
Chronic pain, headaches, GI issues, fatigue, or physical symptoms without clear medical cause.
⚑ Somatic flag — triggers somatic assessment in Phase 5
E
Healthy regulation
Safe outlets, trusted mentors, spiritual practices, or tools to process stress effectively.
✓ Resilience factor
Phase 4 — Compensatory Trajectory
Q4-B
Looking at how you manage emotional pressure or the need for safety in your daily life — which of these subtle strategies do you lean on most heavily?
Select One
A
Keeping my feelings, anger, or needs to myself
To avoid being a burden or risking rejection.
⚑ Emotional suppression — Maté framework
B
Throwing myself into work, tasks, or achievement
To earn a sense of safety, control, or worth.
⚑ Compulsive overworking / perfectionism
C
Using food, screens, distraction, or substances to soothe
To quiet a restlessness I can't quite name.
⚑ Self-medicating / numbing pattern
D
Focusing entirely on managing other people's moods or needs
So I don't have to feel my own vulnerability.
⚑ Hyper-vigilance / caretaking — fawn pattern
Phase 4 — Compensatory Trajectory
Q4-C
The ways you've learned to cope — what do they cost you?
Select All That Apply
A
Exhaustion
I frequently hit walls of exhaustion — physically, emotionally, or both — that I can't push through.
⚑ Burnout pattern — high adaptive load
B
Loneliness
Even surrounded by people, my coping keeps me feeling isolated or misunderstood.
⚑ Relational disconnection — bridges to Phase 6
C
Physical symptoms
My body holds the tension — stress shows up as tightness, fatigue, or pain when I try to slow down.
⚑ Somatic cost — coordinate with Phase 5
D
Being stuck
I want to change these patterns but they feel like the only thing keeping me safe.
⚑ Ambivalence / resistance — pace session one carefully
Phase 4 — Compensatory Trajectory
Q4-D
When emotional stress, pressure, or a heavy mental load builds up in your daily life — what is your most common automatic habit for finding relief?
Select One
A
Numbing or escaping
Turning to substances, food, endless screen time, or distraction just to quiet the intensity of my inner state.
⚑ Numbing / avoidance pattern
B
Emotional shutdown
Going numb, pulling inward, or detaching completely from people and tasks to conserve energy.
⚑ Freeze / dissociative pattern
C
Overworking or perfectionism
Pouring myself into productivity, control, or achieving goals so I never have to feel vulnerable or out of control.
⚑ High-functioning internalizer — Maté pattern
D
Irritability or quick reactivity
Feeling a sudden spike of frustration, anger, or urgency when things don't go as planned or demands pile up faster than I can manage them.
⚑ Externalizing / hyperarousal pattern
Phase 4 — Compensatory Trajectory
Q4-F
When stress or emotional pressure builds up, what actually helps bring you back to a more settled place?
Select All That Apply
A
Physical movement
Exercise, walking, yoga, or any body-based activity.
✓ Somatic regulation resource
B
Creative or meaningful activity
Music, art, writing, cooking, or anything absorbing.
I tend to manage it by pushing through rather than settling it
Productivity or willpower is my main strategy.
⚑ High-functioning avoidance — coordinate with Q4-B and Q4-D
Phase 5 — Somatic Pain Assessment
People who have experienced what you've described often find that emotional pain shows up in the body — chronic aches, tension, or unexplained physical symptoms that doctors haven't been able to fully explain. This is not imagined. It is a real and well-documented response of the nervous system to unresolved stress and trauma.
Q3-A-C-A
Do you experience body aches, tension, or physical pain that others around you don't seem to share or fully understand?
A
Yes — this resonates with me
I have physical symptoms that feel connected to my emotional state or history.
↳ Triggers location and intensity questions
B
Somewhat — occasionally or mildly
I notice some physical symptoms but they're not a major concern.
↳ Triggers location and intensity questions
C
No — I don't notice this for myself
Physical symptoms are not a significant part of my experience right now.
↳ Skips to Phase 6
Phase 5 — Somatic Pain Assessment
Q3-A-C-B
Where in your body do you feel it most?
Select All That Apply
A
Head / jaw / neck
Tension headaches, jaw clenching, throat tightness, or neck pain.
↳ Hypervigilance, suppressed speech, anxiety
B
Chest
Tightness, heaviness, constriction, or chest pain.
↳ Anxiety, grief, unprocessed fear
C
Stomach / gut
Anxiety in the gut, nausea, digestive issues, or chronic stomach pain.
↳ Anxiety, fear response, chronic stress
D
Shoulders / upper back
Carrying weight, chronic soreness, tightness between shoulder blades.
↳ Chronic stress burden, hypervigilance
E
Lower back / hips / pelvis
Chronic lower back pain or pelvic tension.
⚑ Often connected to more complex trauma
F
Arms / hands
Numbness, tingling, bracing patterns, or tension.
↳ Freeze response, physical hyperalertness
G
Legs / feet
Heaviness, numbness, disconnection from the ground, or restless legs.
↳ Freeze response, dissociation
H
It moves around
Multiple shifting locations — hard to pin down.
I
Whole body / hard to pinpoint
A general heaviness, fatigue, or full-body tension.
Phase 5 — Somatic Pain Assessment
Q3-A-C-C
How much does this physical pain or tension affect your daily life?
3
Moderately disruptive — affects mood, energy, or activities regularly.
1 — Barely noticeable5 — Severely disruptive
Phase 5 — Somatic Pain Assessment
Q3-A-C-D
When did you first notice these physical symptoms?
I can generally stay grounded, communicate my feelings, and navigate the discomfort
I don't always get it right, but I can usually find my footing.
✓ Secure attachment baseline
Phase 6 — Relationships & Attachment
Q3-A-B-A-C
Do you notice physical tension, gut issues, or somatic symptoms flare up when you're experiencing relational stress, emotional vulnerability, or conflict with someone close to you?
A
Rarely or never
My body doesn't seem to react strongly to relational stress.
B
Yes — my body tends to hold relational stress immediately
I notice physical symptoms when there's friction or emotional intensity with someone I care about.
⚑ Somatic-attachment link — coordinate with Phase 5 data
C
Frequently — physical symptoms often show up before I even realize I'm upset
My body signals relational distress before my mind catches up.
⚑ Strong somatic-attachment link — clinician note
Phase 6 — Relationships & Attachment
Q6-D
Most of the time — even when things are going well — what underlying belief or fear tends to run quietly in the background?
Select One
A
"If I am not perfect, successful, or useful, I won't be valued or loved."
⚑ Fear of inadequacy — anxious/preoccupied working model
B
"If I show my true needs or let my guard down, people will eventually leave or let me down."
⚑ Fear of abandonment — anxious attachment working model
C
"If I let someone get too close, I will lose my autonomy, freedom, or safety."
⚑ Fear of enmeshment — avoidant attachment working model
D
"I cannot depend on anyone else — if things are going to be okay, I have to carry it all myself."
⚑ Burden of self-reliance — dismissive avoidant working model
Final Question — What You've Already Tried
This is the final question. Understanding what you've already tried can help a clinician build on what's worked and avoid repeating what hasn't. This is not a judgment.
QF
Which of the following have you tried in the past or are currently using?
Select All That Apply
A
EMDR
Eye Movement Desensitization and Reprocessing therapy.
B
CBT / talk therapy
Cognitive Behavioral Therapy or traditional talk therapy.
C
Medication / psychiatry
Prescribed medication for mental health or psychiatric evaluation.
Yoga, tai chi, somatic movement, or body-based wellness practices.
F
Acupuncture or bodywork
Acupuncture, massage therapy, chiropractic, or other hands-on treatment.
G
Journaling
Regular reflective writing as a coping or processing tool.
H
Support groups or peer support
Group therapy, 12-step, community support groups, or peer-led programs.
I
Faith or spiritual practice
Prayer, church, spiritual community, or faith-based support.
J
Exercise or physical activity
Using movement and exercise as a primary coping strategy.
K
Nothing yet — this is my first step
I haven't tried formal support before.
⚑ New to treatment — clinician: pace session one carefully
Almost Done
Your personalized summary is ready.
Before we show you your results, please share your name and email so Clearpath can connect your intake to the correct record. This information is kept confidential and is never sold.
✓ Questionnaire complete
A Clearpath clinician will review what you shared
Thank you for completing this. A Clearpath clinician will review what you shared. If you decide to continue with services, they can discuss it with you and answer questions.
This reflection is educational and is not a diagnosis. Completing this intake does not guarantee services or establish a therapist-client relationship.