Intake form. Fill out to complete registration for service with Iryna Yeromenko, Clinical Hypnotherapist
Hello and Welcome to ReUmagine. Please fill out this intake form to the best of your ability. All the information you provide is strictly confidential.
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Email *
Name *
Last Name *
Preferred Name *
Address: Street Address, City, State, Country *
Phone number. Please not that for calls outside of USA & Canada, we will connect on What's App. *
email *
Sex *
Marital status *
Age *
Date of birth *
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Occupation *
Emergency contact: Name, relationship and phone number *
Primary Care Provider:  Name, address, phone number *
Are you currently receiving any treatment from a Doctor or other Practitioner? If yes, please give brief details: *
Are you currently taking any medication? If yes, please give details: *
Please give a brief background of your current concern: *
On a scale form 1 to 10, how committed are you to resolving this problem? *
Have you previously tried to resolve this issue? *
If the answer to the previous question is yes- what have you tried? Mark N/A if you answered NO to to the previous question.
What do you wish to receive from your session? *
Mark any of the below issues that are current concerns for you. *
Required
How did you find out about ReUmagine? *
Are you ready to invest at least 30 min a day for at least 21 days to achieve your goal? *
Are you ready to invest financially to achieve your goal? *
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