Intake Form

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Intake Form

Email *

First Name *

Last Name *

Phone Number *

Age *

Relationship status *

What would you most like me to help you with? *

Can you tell me what your symptoms, triggers and habits are for the issue that you would like to work on? *

Who was your primary care taker when you were a child? *

Is there anything about your family that you think may be relevant to how you are today? *

What would you like to achieve from our session? *

What will your life be like without this issue? *

Who is the best version of you? (How would you feel, what would you look like, who would you be?) * *

Is there anything else you think I need to know?

Send me a copy of my responses.

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