Client Intake Form

Client Intake Form

Angela Wadley/Karma Star Healing Arts
Please complete this form (All information is strictly confidential)
Name

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell #:
Birth Date:

MonthDayYear
Date
Email Address:
Sex:
Marital Status:
Occupation:
Have you ever been treated for an emotional problem?

YesNo
Please explain:
Have you ever been treated for:

DiabetesEpilepsyHeart DisorderDigestive Problems
Have you ever experienced NLP, EFT or been hypnotized before?

YesNo
Please explain
What do you want to accomplish through the use of Hypnosis/NLP/EFT or any other services offered?
Any previous efforts to solve this problem?

YesNo
Results?
How did you hear about Angela?

Medical ReferralRelativeFriendPodcastTelevisionOnlineOther
Please type the name of the podcast
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 and/or NLP and/or EFT I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy and/or NLP and/or EFT 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 old illnesses.
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Date:

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Name I like to be called:
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