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?

How did you find us?

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

Do you take any medication currently? Which one if so?

Relationships quality: partner / family / with yourself / At work

Center or interest, hobbies, what you like, feel good at

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?

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.