Gym health questionnaire Form

Intake Form
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Emergency contact*

First NameLast Name
Phone number*
History

Let's get to know each other.
Have you ever sought support for emotional issues? (Yes / No)

YesNo
If yes, please provide relevant details.
Have you ever been treated for medical problems (check any that apply)

DiabetesDigestive problemsEpilepsyMental HealthHeart DisorderOther
Any other medical condition, please list here
Have you ever been treated with NLP techniques or Hypnosis before? If yes, please explain
What are you aiming to improve while working with Libby?

HealthRelationshipsWeight lossSmoking
What are your goals for working with Libby?
Have you sought support for this issue previously? If yes, please provide details.
Do you have any phobia's?
Is there anything else you feel important for Libby to understand or be aware of before commencing coaching with her?
Agreement

I am willing to be guided through relaxation, visual imagery, creative visualisation, hypnosis, timeline techniques, and stress reduction processes and techniques for the purpose of vocational 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 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 doctor for treatment of any new or old illness.
Initials*

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Date

JourMoisAnnée

MinutesAM/PM Option
Should be Empty:

Intake Form

History

Agreement