Initial Intake Form

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Initial Intake Form

Katalin Nagy Intake Form

Email *

PERSONAL INFORMATION

Full Name *

Preferred Name *

Telephone *

Address *

Date of birth *

YYYY

Marital/Relationship Status: *

Occupation *

Next of Kin and relationship to Client *

Next of Kin's Telephone *

Next of Kin's Address *

Next of Kin's Email address *

HEALTH

Health issues, medications taken (please refer to Contraindications at the end of this form).
Please note that the Therapist/Coach can not take responsibility for the answers given, however they can refuse treatment if the answers indicate that the treatment provided by Therapist/Coach is not suitable for Client due to certain mental or physical health conditions and/or medications taken.

Medications being taken *

Hypnosis is not recommended in the case of taking certain medications that are altering information processing abilities (please refer to Contraindications at the end of this form).

Health Problems (Past and Present) *

Doctor's Name, Address and Telephone number *

Date of Last Check-up *

YYYY

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