Client Intake Form

Customer Intake Form
Email
example@example.com
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number with Country Code
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method (Email / WhatsApp / Facebook Messenger / Other)
Relationship status
Occupation
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number (with country code)
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Name and Address
Date (month & year) of last check up
Health Problems (relevant past and current)
Medications being taken
Potential Areas of Concern - please check all that apply
What is your biggest current problem that you wish to work on during your session?

Please rate the following areas from 1-10. 1=Very problematic, 10=Amazing

What is it that you absolutely want as a result of your session?
How committed are you to this change in your life? 10=Absolutely committed
How did you attempt to solve this issue in the past?
Have you been hypnotised before?
Mental Leap Hypnotherapy is unable to provide sessions for people with epilepsy, schizophrenia, psychosis, or who are diagosed and on medication for bi-polar disorder. By ticking this box you acknowledge that you do not have any of these conditions.
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Customer Intake Form