Intake Questionnaire

KIRI GLEN

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Questionnaire

* Indicates required field

Name *

First

Last

Email *

Cell Phone Number *

Age *

Emergency Contact name and phone number *

Your Occupation *

Relationship Status *

Current health issues and medications *

Select all areas that are a concern for you *

Addictions Smoking Drinking Drugs Compulsive Behaviour Self Esteem Confidence Anxiety Stress Fears Panic Attacks Phobias Guilt Eating disorder Weight problems Depression Motivation Procrastination Career Issues Public speaking Focus Memory Relationships Childhood problems sexual problems sleep problems

Other (please specify) *

What is the issue you'd like to work on? *

How long have you been struggling with this issue? *

How is this currently impacting your day to day life? *

What is the outcome you are hoping to achieve and how might that change your day to day life? *

On a scale of 1-10 (10 being highest), how motivated are you to resolve this issue? *

What social media platform do you use the most? *

Facebook Instagram Twitter Pinterest Don't use social media

How did you find Kiri Glen Hypnotherapy? *

Referral Facebook Instagram Event / in person contact Internet search

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