Vicki Tracy PLLC Intake Form

Your thoughtful response to these questions provides helpful context for me as we begin our work together. Please take 15-20 minutes to complete this form. Information in this form is kept confidential

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Before we go too far, if you are planning on seeing me in person please be aware that there is one flight of stairs to navigate to get to my office.  Please check the response below that best fits.  *
First and last name *
Email address *
Phone number *

What has you seeking a session with me at this time? Is there something specific, such as a particular event or physical symptom? Be as detailed as you can. 

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What is your problem/challenge preventing you from achieving?

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What area of your life do you feel is preventing you from solving this problem on your own?

Do you have any concerns, fears or hesitations about Whole Health Intuitive Energy healing?

Please list, if any, prior experiences of Reiki, BodyTalk, Hakomi.  Just list “none” if no prior experience.  
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Please check any of the following you have experienced or felt in the last 6 months:
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Required
Please list any major life events I should be aware of (previous injuries, accidents, surgeries, marriage, divorce, death, change of job, moving). Please include approximate dates:

How many hours a night do you sleep?

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Is your sleep restful? If not, please describe.
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What do you do for work? How long have you been doing it? Briefly describe your work environment.
If you are experiencing any physical pain, please list the areas of your body affected, and rank the discomfort of each area on a scale of 1-10.   example: Left Shoulder -2 

1. Slight awareness of discomfort.

2-3. Awareness of discomfort as an aggravation.

4-6. Pain is strong but you are still functional.

7-9. Pain is so strong you are unable to function normally.

10. You feel like you need to go to the emergency room.

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How did you hear about me?
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On occasion I send out a newsletter to keep you updated on offerings. May I put you on my mailing list?
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What is your most desirable outcome with working with me?
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What else would you like me to know?

My emergency contact's name and phone number is:
Digital Signature: Type name in answer box

* I agree that I have answered all of the above questions to the best of my knowledge. I consent to sharing the information provided here.
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