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BiaBliss.com - New client intake form
Full Name (First/Last) *
Your answer
D.O.B *
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Age *
Your answer
Phone number *
Your answer
Email *
Your answer
Location (Town/Suburb) *
Your answer
Gender *
What is your marital status? *
If you are currently in a relationship, is your partner aware that you are attending a session with Bia Bliss? *
What are you interested in ? Tick all that apply *
Required
Do you have a history of sexual abuse or trauma?
Are you currently on any prescription medication or have been in the last six months? If yes, briefly explain in the 'other' box *
Required
Do you have any experience with embodiment practices such as yoga, breathwork, meditation, mindfulness? Tick all that apply *
Required
What is your desired outcome from your session/s with Bia Bliss? *
Your answer
Is there anything else you would like Bia Bliss to know about?
Your answer
Where did you learn about Bia Bliss' services? If 'other', please explain *
I acknowledge that in order for Bia Bliss to provide the best support possible, I am encouraged to speak the truth, regardless of how uncomfortable or embarrassed I may feel at the time. Please write your name on the "other" box if you agree. *
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