Intake and Consultation Form

Name

ForenameSurname

Preferred Name:

Date of Birth

Date

Age

Occupation

Address

Mobile Number

Please enter a valid phone number.Format: (000) 000-0000.

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:

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

Signature