Lifting Consciousness Academy ✨ Counselling/ QHHT Intake Form
The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and as accurately as you can, you will assist me in optimising your time and ensure I am the right person to guide you. These data are protected with privacy & confidentiality (The Australian Privacy Act 1988)
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
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
Gender
Male
Female
Other
Prior experience with QHHT or hypnotherapy?
Yes
No
What do you hope to achieve with our session?
*
Give a brief account of the history and development of your situation.
Do you have any fears or concern? Please explain them.
Current health status: include any injury or condition, and medications if any.
Relationship with father and mother
Number, Gender and relationship with Siblings
If any, list children and ages with a short personality description of each.
Any other significant/relevant relationship
What is your occupation?
What are your interests/passions?
Check areas you would like to resolve or improve.
Children
Friends
Other family
Communication
Work
Finances
Substance abuse
Recreation/leisure
Religious differences
Arguments
Any form of abuse
In-laws
Spirituality
Life’s lessons
Purpose
Other Lives
Other
Is there any other information/concerns I should know? Any question you have?
Submit
Should be Empty: