Intake and Consultation Form

Intake and Consultation Form

Strictly confidential
Name*

ForenameSurname
Preferred Name:*
Date of Birth*

MonthDayYear
Date
Age*
Occupation*
Address*
Mobile Number
Please enter a valid phone number.
Email*
example@example.com
Relationship status*
Children: (inc. ages/ gender)*
If none please write N/A
Hobbies*
Doctor/Practice*
Last appointment: (approx.)*
Any diagnosed Medical Conditions*
Medications currently taken*
Describe briefly the main issue/ problem you would like us to work on*
Health Probelms (Past & Current) - From the list below please tick the areas that concern you:*

AddictionsDrinkingSmokingDrugsGamblingCompulsive BehaviourAnxietyStressFearsPhobiasPanic AttacksGuiltRelaxationEating ProblemsFood/DietWeight ProblemsAnorexiaBulimiaExerciseDepressionConfidenceSelf EsteemMotivationAchieving GoalsProcrastinationCreativity & inspirationCareer IssuesInterview SkillsNervesPublic SpeakingConcentrationFocusExamsMemoryDriving SkillsRelationshipsChildhood ProblemsSexual ProblemsFertilityPain ControlHearingSight/VisionMobilitySkin ProblemsHair GrowthSleep Problems
Tell me 3 or 4 things you are proud of in your life today.*
Describe briefly the main issue / problem you would like us to work on: *
What are the triggers to the issue?*
What are the symptoms you are experiencing?*
What are the habits that induce the issue?*
Briefly mention some background information on your family, your childhood or relevant past.*
Relationships with siblings, parents & guardians, and/or any important situations & experiences.*
Anything else you would like to mention?
Is your current home a happy/safe place to be?*
Tell me 3 or 4 things you are proud of in your life today.*
If I had a magic wand and I could grant you one wish with this session, what would that be?*
What is the outcome you want to have from our session?*
Please take 5-10 minutes to imagine what your life would be like without the issue. Describe in as much detail as you can about the new life.
What would it look like?*
What would it feel like?*
What would be different?*
What would you be hearing?*
What would you be experiencing in your day?*
How would you like to be in the situations that currently trigger your issue?*
Instead of your current symptoms, how would you like to be (behaving/feeling/doing)?*
What phrases & keywords would you encourage you and are important for you to hear in the transformation I create for you?*
e.g. I have amazing coping skills, I am incredibly resilient, I am loveable, I leap out of bed effortlessly in the morning with incredible energy.
Please choose the option(s) that best describe you as a child. If you don't feel any apply, please leave blank

The sick oneThe one who cared for the othersThe brilliant and successful oneThe rebel, the black sheep
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