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