Elevate with Rosa: Intake Form
For any questions, please contact Rosa Patrinostro, RCH, at ElevateWithRosa@gmail.com
Welcome to Elevate with Rosa: Thank you for choosing my Clinical Hypnotherapy Practice - Elevate With Rosa. I am a certified Clinical Hypnotherapist registered with the Association of Registered Clinical Hypnotherapists(ARCH Canada).
Please review T&C, Confidentiality Clause and the Scope of Work Sections
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
Gender
*
Male, female, other
Marital Status
*
Married/Common Law
Single
Divorced
Other
Relationship History
*
How did you hear about Elevate with Rosa
*
Facebook, Instagram, YouTube, Other
What is the reason for your visit?
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Give a general idea of what you want to work on
Do you have thoughts of hurting yourself or taking your own life?
*
Yes
No
List any current health issues
*
Do you have a family doctor?
*
Yes
No
If yes, what is your doctor's information
First Name
Last Name
What is your doctor's phone number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your doctor's email?
example@example.com
What is the doctor's contact information?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you discussed with your health provider about hypnotherapy as an adjunct to your treatment?
*
Yes
No
Have you ever been treated for emotional issues from a licensed professional?
*
Yes
No
if yes, are you currently receiving treatment or counselling?
*
Yes
No
If yes, what is the name of the counsellor or therapist?
First Name
Last Name
Have you ever been diagnosed for an emotional disorder
*
Yes
No
If yes, what was the diagnosis?
What is the most important goal you want to achieve right now?
*
On a scale of 1-10, 10 being the most, how ready are you to make the necessary changes to achieve this goal?
*
Provide other information about this goal in greater detail if necessary
What are your spiritual beliefs and what term do you use to refer to God?
*
Please share anything else that we helpful to know more about you.
*
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