Private Healing Session Intake Form
STRICTLY COFIDENTIAL
Email address *
First Name *
Last Name *
Preferred Name/Nickname
Phone *
State/County *
Address *
City *
Zip/Post Code *
Country *
Date of Birth *
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Age *
Marital/Relationship Status *
Employer *
Occupation *
Doctor's Name *
Date of Last Check Up *
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Please check if you have or have had a history of *
Required
Have you ever had any serious illnesses, surgeries, chronic viral inflections or traumatic accident? If so, what and when? *
Are you presently under a doctor's care of taking medications? If so, please list and describe for what conditions?
Are you pregnant? *
Do you have any pain or discomfort? If so, where, what kind of pain or discomfort, and how much? (0 - 10, with 0 being no pain and 10 being the worst pain you can imagine.) *
Do you exercise? If so, how much and what kind of exercise? *
What is your Physical stress level (0-10, “0” being no stress) & why? *
What is your Emotional stress level (0-10, “0” being no stress) & why? *
How is your sleeping pattern? *
Please list and describe others:
How is your digestive system? *
How many bowel movement? _____per day ____ per week *
What is your appetite? *
Do you have any allergies? If so, what? *
Please check ALL the areas below that concern you: *
Required
Please list and describe others:
If you had to choose ONE, MOST IMPORTANT ISSUE to focus on in your session, what would it be and why? *
*Example: "Anxiety because it keeps me from focusing on my work, making money, keeps me up at night and stops me from being present with my friends and family, etc..."
What would you like to get out of your session? *
*Example: "getting a rid of the anxiety"
If you no longer struggled with this issue, how would it impact your life? How and what would your life look like, and how would you like to feel without the issue? *
Be specific the words and phrases you share are essential to the new beliefs you create. How would it impact your work? Your relationships? Your health? Your finances? Please give specific examples.
What's your ultimate desire? What are your LONG term goals? *
What is your big dream and desire for your life? To feel free and financial secure? To travel the world with your partner? Don't hold back!
Is there anything else I should know before we start?
How did you find about "Ryoko Suzuki - Holistic Healing & Wellness"? *
What is your usual available days/times (in CT)? *
*Example: Mondays 10am-12pm, Tuesdays 3-6pm, etc...
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