Cuantic System Intake Form
Email address *
FULL name
Your answer
Date of birth including year
Your answer
Address including city and country
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Phone number
Your answer
Email
Your answer
Marital Status
Medications
Your answer
Think about your main problem. Is it more physical, emotional or mental? Use the numbers 1, 2 and 3 to indicate which has first, second and third priority.
PHYSICAL
Your answer
EMOTIONAL
Your answer
MENTAL
Your answer
Explain your main problem:
Your answer
When did the problem begin?
Your answer
Is there any other experience that you think perhaps is related to this problem? For example, a separation, death of a loved one, financial issues etc.? If yes, explain and include dates of occurrence.
Your answer
How do you feel in relation to the problem?
Your answer
How bad is the problem right now?
Worst possible
Best possible
How would you like to be feeling instead?
Your answer
Please say what you have tried already to help yourself with the problem.
Your answer
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