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FIND YOUR LIGHT PROGRAM
General Session
Smoking Cessation
Weight Loss
FREE Consultation Call
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For Clients
Disclosure Form
Client Intake Form
Testimonial Entry Form
FAQ
Client Intake Form
Name
Date of Birth
Preferred Name
Relationship Status
Email
Phone Number
Occupation
Doctor's Name
Address
Doctor's Address
Emergency Contact Name and Phone Number
Doctor's Phone Number
Medication being taken and for what purpose/condition?
Medical Health History (Past and Current)
Why are you seeking therapy?
Everyone wants a 10 out of 10 life. What mark out of 10 would you give your life right now?
Please Tick ALL Areas of Concern
Drinking
Smoking
Drugs
Gambling
Compulsive Behavior
.
Anxiety/Nerves
Fears/Phobias
Panic Attacks
Sexual Problems
Conception / Pregnancy
.
Food/Diet
Anorexia
Bulimia
Exercise
Mobility
.
Depression
Confidence/Self Esteem
Motivation/ Goals
Childhood Problems
Relationships
.
Career Issues
Public Speaking
Exams
Pain Control
Insomnia
I confirm that I have been advised by The Practitoner of the scope of the therapies that she provides and give my full consent to receiving therapy sessions
I confirm that I have read and accept all terms and conditions as stated in Disclosure Form
DISCLOSURE FORM
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