Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Birthdate
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Marital Status and Occupation
Emergency Contact
Are you taking any medication? If yes, please state.
Have you had any other forms of therapy before?
Please describe your relationships with your family.
Please choose which issues you would like to be addressed. You can choose as many as you like, and please be aware we may not be able to address every single issue in one session.
Are there any other issues not listed?
If you have more than 1 issue please identify the top 3 issues you feel impact your life currently.
What are the main triggers, symptoms, and action/ habits, and behaviors around your issue(s)?
When did the issues first present themselves?
What was going on in your life when the issue(s) started?
On a scale of 1-10 how much do you want to overcome your issue (1 is not motivated to achieve what you want to overcome, 10 is highly motivated).
What outcome would you like from the session? What will your life be like without the issue?
Submit
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