MFRCenter NLP/Hypnotherapy Intake Form
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Email *
BASIC INFO
Date *
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First Name *
Last Name *
Address *
Email *
Cell Phone *
Employer *
Occupation *
DOB *
MM
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DD
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YYYY
Age *
Gender *
Marital Status *
Number of Children *
Emergency Contact Name *
Emergency Contact Phone Number *
YOUR ISSUE
What's the issue that you're ready for me to help you resolve? *
How big of an issue is this in your life? *
What areas of your life does this involve? *
Required
Do you consider this to be more of a problem, or a goal? *
Select any of the following that applies to your issue: *
Required
Do you want to resolve it, or do you 'want to want' to resolve it? *
What has this issue cost you so far in your life (time, money, suffering, lost opportunities,sacrifice, etc.)? *
What has been this issue's biggest cost to you? *
If left unresolved, what could this issue end up costing you over the next 10 years? *
Are you looking for a quick fix, or are you ready to sincerely commit to doing what it takes to resolve this? *
How committed are you to resolving this? *
What have you previously invested in to help you with this? *
What characteristic(s) are most important to you in a coach or therapist? *
Required
How would you rate your ability to follow instructions? *
MORE ABOUT YOU
What’s most important to you about resolving this issue? *
What are your main strengths? *
What are your main limitations? *
List 5 or more of your most meaningful accomplishments: *
HEALTH & FITNESS
Primary care physician name & number: *
Please list any current treatment being received from any health care providers: *
Please list any current medications and dosages: *
How often do you exercise? *
What type(s) of exercise do you engage in? *
Hours of sleep required? *
What is your normal bedtime? *
Do you have difficulty falling asleep? *
Do you have difficulty staying asleep? *
Which of the following physical complaints currently apply to you? *
Required
Which of the following emotional complaints currently apply to you? *
Required
RECENT LIFE CHANGES
Health Changes *
Required
Home / Family changes *
Required
Financial changes *
Required
Work changes *
Required
Cancellation Policy
We have a 24 hour cancellation / rescheduling policy: Cancelled, changed or missed appointments with less than 24 hours notice will result in the loss of that session (value $125). a fee of $70. This policy is in place out of respect for our therapists, and our clients, because an appointment cancelled with less than 24 hours notice results in a time slot that is difficult to fill, and giving last minute notice or no notice at all prevents others from being able to schedule into that time slot.Thank you for your understanding and cooperation.
I understand and agree to the policies described above.
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