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Claudia Kervin
HYPNOTHERAPY
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Please Complete this Intake Form
This information will help me personalise your program to achieve the desired outcome.
All sensitive information has an added layer of protection for your data's safety
Surname
*
Forename
*
Preferred Name
Date of Birth
*
Month
Address
*
Relationship Status
*
Occupation
*
Email Address
*
Phone Number
*
HEALTH
Your Doctor's Name
*
Your Doctor's Address
*
Date of Last Checkup
*
Medication Being Taken
*
HEALTH PROBLEMS
(past & current)
Select
areas of concern
from the list below:
______________________
Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
______________________
Depression
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
______________________
Eating Problems
Food/Diet
Weight Problems
Anorexia
Bulimia
Exercise
______________________
Pain Control
Hearing
Sight/Vision
Mobility
Skin Problems
Hair Growth
______________________
Sexual Problems
Fertility
IVF
Conception
Pregnancy
Birth
______________________
Relationships
Childhood Problems
Sleep Problems
______________________
Career Issues
Interview Skills
Nerves
Public Speaking
Concentration
Exams
Memory
Driving Skills
______________________
Anxiety
Stress
Fears
Phobias
Panic Attacks
Guilt
Relaxation
Submit
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