HEALnewyorkcity Intake Form
for New Clients
Email address *
Name *
Your answer
Date of Birth *
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Address *
Your answer
Phone # *
Your answer
Relationship Status
Partner's Name
Your answer
Children &/or well loved pets (names/ages)
Your answer
How did you hear about HEALnewyorkcity? *
Your answer
Are you currently under any psychiatric or medical treatment? If yes, please describe:
Your answer
List any medications you are taking:
Your answer
List any known fears or phobias:
Your answer
What do you do for a living?
Your answer
What do you enjoy doing when not ding that? (hobbies/interests)
Your answer
What comes to mind when you think of a relaxing place?
Your answer
Why are you here? (interested in hypnosis/reiki/life coaching)
Your answer
Is this your first time being hypnotized?
If not, how was your previous experience(s)?
Your answer
Do you meditate?
Do you consider yourself spiritual?
What type of learner are you primarily? (If not sure, just go with your first impression)
What would you like to accomplish in these sessions?
Your answer
How will you know that you have accomplished this? ie: What would be different in your life? (Be specific)
Your answer
What has been stopping you from achieving this?
Your answer
How important is it for you to make this change now?
Not important at all
Extremely important
How ready are you to make this change now?
Not ready at all
Couldn't be more ready
When you have benefitted from our sessions, would you write a short testimonial that may be viewed on the HEALnewyorkcity website?
Your answer
A copy of your responses will be emailed to the address you provided.
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