Intake Form Name * First Name Last Name Today's Date * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Birth Date * MM DD YYYY Parent (If client is a minor) First Name Last Name Marital Status * Check all that apply. Married Divorced Single Dating In a Relationship Not Dating Preferences * What should we know about you to make your experience perfect in every way? Medications * Please list all medications you're presently taking Are you currently seeing another therapist? * Yes No Do you have a psychological diagnosis? * Yes No Are you prone to seizures? * Yes No Are you pregnant? * Yes No Do you wear contact lenses? * Yes No Do you have any heart problems? * Yes No List other diagnosed physical problems * If none, write "N/A" How did you hear about us? * Friend? Social media? Maps App? List members of your family and all others in your home Name, Age & Relationship to you What services are you interested in? * H.E.M.S. Session Hypnotherapy Session Reiki Session Dating & Intimacy Coaching Session Challenges * Please check the box of every challenge you are currently facing in life. Nervousness Shame/Guilt Anger Loneliness Unhappy Stomach Problems Dishonesty Legal Matters Alcohol Use Bowel Problems Sexual Issues Depression Drug Use Sleep Children Tired/Low Energy Appetite Issues Bed Wetting Career Smoking Divorce Self-Image Fears Suicidal Thoughts Headaches Memory Marriage Inferiority Nightmares Self-Control Panic Attacks Phobia Tension Shyness Stress Temper Finances Education Work Parenting Friends Health Ambition Weight What is your goal with us? * (Ex: to be more confident, to create more wealth, to have a better relationship with my partner, etc.) I am willing to record a very short testimonial video at the end of my session Yes No Thank you! We will be reaching out shortly…
