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 *
Preferred Name *
Age and DOB *
Address *
Gender *
Relationship Status *
Required
Children, ages and names *
Occupation *
Email address *
Telephone number *
Emergency contact: name, relationship and phone number *
Primary Health Care provider: name, address and phone number *
Are you currently receiving any treatment from a Doctor or any other practitioner? If yes, please give a brief explanation *
Are you currently taking any medications? *
Health issues, past and/or current *
Have you ever been diagnosed with a mental health condition? If yes, please provide details below. *
Have you ever had a psychotic episode and/or ever been prescribed anti-psychotic medication? If yes, please provide details below. *
From the list below, choose the top 3 areas of concern *
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? *
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. *
What do you think is the cause of this issue? (Childhood event, habits, beliefs, past trauma, etc) *
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 *
How much purified water do you drink per day?  *
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...  *
Why does this matter to you? Why is this important?...  *
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!
*
Have you had hypnosis before? *
If yes, what for and how helpful was it?
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? *
Is there anything else I would need to know?
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