Health questionary - Intake form to prepare your therapy session

Email *

Number

Number (copy)

(copy)

Marital status

Single
Married
In couple
Single parent

The session is for

Prefered location

Main domain of consultation

Which service?

Have you every been diagnosed with a mental condition? Which one?

How did you find us?

Reason of consultation: describe your symptoms, issues, behavior to change… :

Diet

Sports

Medical history

Did you notice any following change?

Relationships quality: partner / familly / with yourself

How is your work environment: colleague, space

How do you feel at your home?

What is your center of interest, things you like doing, enjoy in general?

What is your needs or expectation for this session?

Would you be open to be offer different therapies in your treatment plan, such as hypnosis for example?

Important informations

Recurring pains, loss of a relative, major event or trauma, sensitive subject, recent fracture or body pain

I agree that I need to notice my therapist 24h before if I need to cancel, or I might be charged for the consultation.

Check the box

I understand that If I arrive late, I will have the time left for my session, with no discount.

Check the box

Do you allow us to share specific information in your file with another health professionals that already follows you at the clinic, in order to adjust your treatment plan?

Do you allow us to send you some informations (blog, video) or workshop that can reinforce your therapy treatment?

Health questionnary

Determining the right body mind therapy for you.

Thanks for filling the form, we will get back to you soon.