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Client Intake Form
Hello, and thank you for taking the time to complete this form. Please do so at least 24 hours prior to our session. Rest assured that all the information within this form and during our sessions is strictly confidential.
Im looking forward to speaking with you and supporting you in achieving your goals!
Claudia
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Name and Last Name
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Your answer
Preferred Name
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Your answer
Age and DOB
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Your answer
Address
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Your answer
Gender
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Female
Male
Nonbinary
Transgender
Prefer not to say
Relationship Status
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Single
Married
Divorced
Separated
Other
Required
Children, ages and names
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Your answer
Occupation
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Your answer
Email address
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Your answer
Telephone number
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Your answer
Emergency contact: name, relationship and phone number
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Your answer
Primary Health Care provider: name, address and phone number
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Your answer
Are you currently receiving any treatment from a Doctor or any other practitioner? If yes, please give a brief explanation
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Your answer
Are you currently taking any medications?
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Your answer
Health issues, past and/or current
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Your answer
Have you ever been diagnosed with a mental health condition? If yes, please provide details below.
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Your answer
Have you ever had a psychotic episode and/or ever been prescribed anti-psychotic medication? If yes, please provide details below.
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Your answer
From the list below, choose the top 3 areas of concern
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Addiction
Drinking
Smoking
Drugs
Gambling
Compulsive behavior
Career issues
Interview skils
Nerves
Public speaking
Concentration
Taking exams
Memory
Driving skills
Anxiety
Stress
Fear
Phobia
Panic Attacks
Guilt
Relaxation
Sexual problems
Fertility
IVF
Conception
Pregnancy
Birth
Eating problems
Weight problems
Food/diet
Anorexia
Bulimia
Exercise
Pain control
Hearing
Sight/vision
Mobility
Skin problems
Hair growth
Depression
Confidence
Self esteem
Motivation
Achieving goals
Procrastination
Relationships
Childhood problems
Sleep problems
Other:
Required
Please describe the ONE main concern that you are ready to resolve. What’s the big challenge you are facing at the moment? How long has this been going on?
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Your answer
If your issue is a physical illness or problem, please explain & list your symptoms, doctor's diagnosis, recommendations/prognosis & any information you feel is relevant.
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Your answer
What do you think is the cause of this issue? (Childhood event, habits, beliefs, past trauma, etc)
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Your answer
Explain what your life is like because of this issue. How is it impacting you and/or those around you? Be as descriptive as possible
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Your answer
How much purified water do you drink per day?
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Hardly any
2-4 glasses
4-6 glasses
6-8 glasses
more than 8
For you, what would be the PERFECT OUTCOME in relationship to the issue you are wanting to resolve? You can complete these sentences: "If I had a magic wand, I would be able to.... my life would be.... I would feel... things would unfold...
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Your answer
Why does this matter to you? Why is this important?...
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Your answer
If you had the outcome you wish for, exactly as you desire, how would your life be different than it is now?
Paint the picture of your dream reality as detailed as possible:
Who would you be?
What would you be able to do?
With who? Where?
How would you feel?
What would you be able to accomplish?
What would be different?
Be as specific and detailed as possible. Dream full out!
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Your answer
Have you had hypnosis before?
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Yes
No
If yes, what for and how helpful was it?
Your answer
On a scale of 1 - 10, 1 being not very committed and 10 being extremely committed, where you do you find yourself in resolving the issue listed above?
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1
2
3
4
5
6
7
8
9
10
Is there anything else I would need to know?
Your answer
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