Intake
This intake is mandatory for all clients to have on file prior to booking their sessions. All your personal information is confidential.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
Place of birth
Time of birth, if you do not know type DK. If you are able to ask a parent, or even the closest time is super helpful. You can also check your birth certificate.
List any Religious Affiliation or Spiritual Beliefs:
Marital Status
Children? How many? Ages? If none type N.A.
What days or days of the week are most ideal for you? What times? Be very clear including time zones so we can get you properly scheduled.
Location of session; Zoom/GoogleMeets/FaceTime, Phone(no video just voice, or In Person. For in person detail at home or at my specified location. For please note any important details. For Concierge Services please specify if you would like me to come to you or if you have availability to visit Arizona note that here.
One sentence to best describe your relationship with your father…
One sentence to best describe your relationship with your mother…
List all techniques, processes, modalities, and therapies you’ve explored before this session:
What areas of your life are you seeking to transform?
Are you experiencing any physical symptoms and conditions ?
List any drugs or prescriptions you are currently taking:
Knowing what we don’t want is not the same as knowing what we do want! During your session you will have the opportunity to download and install your own tailor made programs and beliefs to support the life you desire. Thoughtfully consider what beliefs you feel are needed at the subconscious level for the best outcome.
Last, but certainly not least… How did you hear about me?
You will be sent a seperate link if any payment is due !
Submit
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