TigerEye Healing - Client Intake Form

Client Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemaleOther
Please indicate your reason for seeking hypnotherapy services / your area of concern
Do you have any mental or behavioral condition requiring continued treatment by a psychiatrist or psychologist? If so, please explain in detail.
Please indicate if you have been diagnosed with or if you have any of the following conditions, in which case we must have a doctor’s written referral to proceed with your hypnotherapy session: Schizophrenia, Heart Disease, Chronic Depression, Epilepsy, Bi-Polar
If you are taking medications, please provide a list.
Where did you hear of TigerEye Healing?

Client Intake Form