Intake Form
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Instructions
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Welcome to my short intake form! All answers are confidential.
Name
Email Address
Phone Number
Are you over 18?
Yes
No
If you have any physical or mental health diagnoses, are you under the care of someone with the correct license to treat that condition?
Yes I have licensed healthcare for my diagnosis
No I don't have licensed healthcare for my diagnosis
I don't have any diagnoses
What are we working on?
Describe the change you seek to create
Describe how you'll be feeling on the other side of this change
What, if any, are your spiritual beliefs?
What, if any, is your experience with hypnosis/NLP?
Confidentiality, Self-Responsibility, Cancellation Policy
I agree to the
terms and conditions
Signature
I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law