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HEALnewyorkcity Intake Form
for New Clients
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Email
*
Your email
Name
*
Your answer
Address
*
Your answer
Phone #
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Relationship Status
Married
Divorced/Separated
Widowed
Single and loving it
Single and ready for a relationship
In a relationship
It's complicated
Other:
Partner's Name
Your answer
Children &/or well loved pets (names/ages)
Your answer
How did you hear about HEALnewyorkcity?
*
Your answer
Are you currently under any psychiatric or medical treatment? If yes, please describe:
Your answer
List any medications you are taking:
Your answer
List any known fears or phobias:
Your answer
What do you do for a living?
Your answer
What do you enjoy doing when not doing that? (hobbies/interests)
Your answer
What comes to mind when you think of a relaxing place?
Your answer
Why are you here? (interested in hypnosis/reiki/life coaching)
Your answer
Is this your first time being hypnotized?
Yes
No
Not sure
Clear selection
If not, how was your previous experience(s)?
Your answer
Do you meditate?
Yes, I have a consistent practice
Yes, occasionally
I've attempted but my mind is all over the place. I'd like to get better at it
I tried but it's not for me
No, but I'm interested
No, not interested
Other:
Do you consider yourself spiritual?
If so, what do you prefer to call your higher power? (ex. God, Source, the universe etc.)
Your answer
What type of learner are you primarily? (If not sure, just go with your first impression)
Visual
Auditory
Kinesthetic/feeler
Other:
What would you like to accomplish in these sessions?
Your answer
How will you know that you have accomplished this? ie: What would be different in your life? (Be specific)
Your answer
What has been stopping you from achieving this?
Your answer
How important is it for you to make this change now?
Not important at all
1
2
3
4
5
6
7
8
9
10
Extremely important
Clear selection
How ready are you to make this change now?
Not ready at all
1
2
3
4
5
6
7
8
9
10
Couldn't be more ready
Clear selection
Create an affirmation (stated in the positive) of you being your favorite version of yourself:
Your answer
When you have benefitted from our sessions, would you write a short testimonial that may be viewed on the HEALnewyorkcity website or social media?
Your answer
A copy of your responses will be emailed to the address you provided.
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