Client Intake Form

First Name *

Last Name *

Email *

Phone number *

Date of birth *

Address

Street Address *

City

State

Country

Postal code

What professional or community organizations are you a part of? *

Emergency Contact Name *

Emergency Contact Phone # *

Occupation *

Allergies *

Medications *

Do you use nicotine? *

Yes

No

What Nicotine & how much per day?

Names of Western or Holistic providers you are currently under care with. *

*No provider will be contacted without your consent:

Contact Number of Western or Holistic providers you are currently under care with. *

*No provider will be contacted without your consent:

What alcohol & how much per week?

Do you drink caffeine? *

Yes

No

What Caffeine & how much?

How frequently do you exercise? *

Daily

2-4x / Week

Ocassionally

Rarely

Do you consume alcohol? *

Yes

No

What is your primary concern? *

Please rate the severity of your issue *

Approximately when did this issue begin? *

Does it cause you physical pain? *

Yes

No

Rate of the Physical pain

How often do you experience this issue? *

What helps? *

What makes it worse? *

Do you have any medical conditions or injuries we should be aware of? *

Explain any other concerns you would like us to know about: *

1st session goals: *

Long-term goals: *

The journey is just beginning, we'd love to continue to support you. What would you be open to consider? *

Discounted maintenance sessions

Monthly Membership ($47/month): Free resources, access to the Advanced Ai Hypnotherapist, exclusive session discounts

Massage therapy

Yearly retreat (past clients get a 50% discount)

If you have not yet sent your payment, we kindly request payment be made in advance to confirm your first appointment. Please choose your preferred method below, and send after submitting this form. *

Paypal: HeartwiseHypnosis

Zelle: [email protected]

Credit Card

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Client Intake Form

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