Client Intake Form
Healing 4 Purpose, LLC
Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Telephone #
Please enter a valid phone number.
Format: (000) 000-0000.
Cell #
Please enter a valid phone number.
Format: (000) 000-0000.
Home #
Please enter a valid phone number.
Format: (000) 000-0000.
Birth Date
-
Month
-
Day
Year
Date
Email
example@example.com
Sex
Male
Female
Have you ever been treated for an emotional problem?
Please Select
Yes
No
If yes, please explain
Have you ever been treated for: (select all that apply)
Diabetes
Epilepsy
Heart Disorder
Digestive Problems
Have you ever had a coach before?
Please Select
Yes
No
If Yes, please explain:
What do you want to accomplish through coaching?
Any previous efforts to solve this problem?
Please Select
Yes
No
Results?
How did you hear about us? (Select all that apply)
Medical Referral
Relative
Friend
Newspaper
Radio
Television
Phone Book
Other
Do you have any fears or phobias?
I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or oldillnesses.
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