EMPOWR Client Intake Form
The purpose of this questionnaire is to obtain a comprehensive picture of your background and what you are looking to achieve. By completing these questions as fully and as accurately as you can, you will assist me in maximizing your time, achieving the fastest results and ultimately saving you money. These details are vital to help determine your success with The EMPOWR Method before proceeding. All information provided is privately secured and stored.
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Other
Marital Status
Married
Re-married
Engaged
Separated
Divorced
Widowed
Single
Other
Job Title
Emergency Contact or Medical Provider
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prior experience with hypnotherapy?
*
Yes
No
Previous therapy or counseling experience?
*
Yes
No
Check areas where problems exist.
*
Motherhood/Children
Divorce/Break up
Sex
Trauma
Work
Finances
Substance abuse
Confidence/Self Esteem
Relationship w Narcissist
Self Identity
Verbal abuse
Single Motherhood
Physical abuse
Spouse/Significant Other
Lack of confidence/self-esteem
Anxiety
Depression
Stress
Sleep issues
Friendships
Life Purpose
Other
Please provide a few additional details on any checked areas above or why you are seeking therapy and how long you've been experiencing these issues approximately.
*
What do you hope to achieve with The EMPOWR Method?
*
List chronic illnesses and injuries.
*
List any medications you are taking daily. (Any psychiatric/potentially mind altering medications)
*
How would you describe your sleep quality?
Very good
Good
Fair
Poor
Mental Health History (Check all that apply)
*
Previous diagnosis of mental health condition
Previous psychiatric hospitalization
Previous suicide attempt/self harm
Family history of mental illness
History of psychosis
History of visual/auditory hallucinations or schizophrenia
No prior mental health history
Do you use any substances? (Check all that apply)
Tobacco
Alcohol
Recreational drugs
Pills
None
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Preferred time of day to contact for FREE Clarity Call
*
Morning (8-11am)
Afternoon (12-4pm)
Evening (5-8pm)
Weekends
On a scale of 1-10, how committed are you to overcome your presenting challenge?
*
Please verify that you are human
*
Type your full name here
*
Signature
*
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