Intake Form DEMOGRAPHICS Name(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Birth Date(Required) Month Day Year Gender(Required) Female Male Prefer not to say Other Please SpecifyPreferred Pronoun(Required) She/Her He/Him They/Them Ze/Zir Other Please indicate your preferred pronounOccupation(Required)Cell Phone(Required)Email(Required) LIFE STYLE Number of Exercise per week(Required) 0 1 2 3 4 5 6 7 Number of cigarettes smoked per day:Number of Alcoholic beverages per day(Required) 0 1 2 3 4 5 or more Amount of sugar per day:(Required) Minimum Moderate Excessive Amount of toxic exposure such as radiation, chemicals, etc.(Required) Minimum Moderate Excessive Stress Levels:(Required) Minimum Moderate Excessive Allergies:(Required) Minimum Moderate Excessive SERVICE INFORMATION Which service will you be receiving?HypnosisHypnosis and BiofeedbackBiofeedbackReikiReiki and BiofeedbackMeditationStrategic Counseling If your visit is for quitting smoking,DO NOT SMOKE for at least 4 HOURS BEFORE your session. If your visit is for weight loss, Bring a small sample of any foods you have an extreme craving for Please describe your goals for this service:(Required)Do you suffer from any diseases, whatsoever, such as Heart Trouble, Lung Disorders, Epilepsy, Diagnosed Depression, etc.?:(Required)Are you currently under a physician’s medical treatment, psychiatric treatment or other medical care? If yes, then please explain:(Required)Are you currently undergoing any sort of therapy? If yes, then please explain:(Required)Are you currently taking any prescribed medications? If so, please list:(Required)Relationship to Client:(Required) Self Parent/Guardian Other Please indicateIs the client specified above a minor, under 18 years of age?(Required) Yes No BIOFEEDBACK REQUIRED INFORMATION Full Name at Birth(Required)Time of Birth(Required)Place of Birth (City, State/Country)(Required)Are you pregnant or possibly pregnant?(Required) Yes No Do you have epiliepsy?(Required) Yes No Do you have a pacemaker or a heart condition?(Required) Yes No Indicate only conditions which are chronic or persistant Abscess Acne AIDS Addiction Addison's disease Adenoids Adrenals Alcoholism Allergy Alzheimer's ALS-Amyotrophic Lateral Sclerosis Anorexia Anti-Aging Anxiety Increase Appetite Decrease Appetite Arm Arteries & Veins Arthritis Asthma Athlete's Foot ADD & ADHD Autism Bacteria Balance Disorder Baldness/Alopecia/Hair Loss Bloating Blood Analysis Blood Analysis Bones Bowel Flora Bronchitis Cancer Candida Carpal Tunnel Chlamydia Cholesterol Crohn's Disease Chronic Fatigue Circulation Cold/Flu Colic Coma Conjunctivitis Constipation Cough Cranial Bones Cuts/Wounds Cystitis Cysts Dandruff Deafness Degeneration Dental/Toothache Depression Diabetes Diaphragm Diarrhea Digestion Dizziness Dyslexia Ear Eczema Elbow Emotional Concern Endocrine Endometriosis Energy Enzymes Endocrine Endometriosis Energy Enzymes Epilepsy Esophagus Eyes Fainting Fat Digestion Fear/Phobia Fertility Fever Fibromyalgia Fibrositis Fibrous Tissue Flatulence Food Poisoning Fungus Gall Bladder Stones Gangrene Gastritis General Digestion Glands Gums Hay Fever Headache Heart Heart Exhaustion Hemorrhage Hemorrhoid Hepatitis Hernia Herpes Hip Bones Hormones Hydration Hypertension Hypochondriac Hypoglycemia Hypothalamus Hypothyroid Immune System Impotence Incontinence Indigestion Infection Inflammation Injury Insomnia Intestines Irritable Bowel Syndrome Itch Jaundice Kidney Kidney Stones Kidney Stones Knee Lactation Lactose Intolerance Laryngitis/Larynx Leaky Gut Syndrome Learning Disability Leukemia Liver Lou Gehrig's Disease Lower Back/Sciatic Lungs Lupus Lyme Disease Lymph Macular Degeneration Malaria Measles Memory Menopause Menstruation Metacarpal Tunnel Syndrome Miasms Migraine Miscarriage Moles/Warts Mononucleosis Motion Sickness Multiple Sclerosis Mumps Neurological Nightmares Obesity Osteoporosis Ovary Oxygen Pain Management Palpitations Pancreas Paralysis Parathyroid Parkinson's Disease PH Balance Pharyngitis Phobias Pituitary Pleurisy Pneumonia Poison Ivy/Poison Oak Prions Prostate Rash Rheumatism Schizophrenia Seizures Sexual Desire STD Sinuses/Sinusitis Skin Sleep Apnea Spasm Speech Spine Spleen Sprain Sterility Stomach Stress Reduction Stroke Sweating Tendonitis Thoracic Throat Thymus TMJ Tonsillitis Tuberculosis Tumor Ulcers Varicose Veins Vertigo Virus Vocal Disorder Vomiting Warts & Moles Weight Loss Worms Wound Repair Wrist Pain Yeast Infection Perfect Health! No Conditions TERMS FOR HYPNOSIS/REIKI SERVICES I fully understand that in no way is the (called in NY State non-therapeutic) consulting hypnosis/reiki in this or any session, private or group, or via reinforcement modality to be a replacement for my physician, any medical treatments or counseling or therapy of any kind that I may need, may be undergoing or may require, as required by my doctor, therapist or as prescribed by law. I further state that I do this of my own free will and I do this as a method of personal self-development / wellness and as with any modality, all results achieved or not achieved are my personal responsibility and in full conjunction with and acknowledgement of all attending medical and psychological professionals whose care I am or may be under. It is fully understood and agreed to, the use clinical hypnotism/reiki and or discussion in this session including any and all work provided, is limited to the complementary use of hypnotic/reiki arts and sciences to enhance the natural restorative and coping abilities of the client. Consulting Hypnotists/Hypnotism helps ordinary, everyday people with ordinary, everyday problems using individual hypnotic techniques. I understand that I am fully responsible for any and all outcomes achieved or not achieved. I fully understand and hereby agree that the practitioners at Self Empowered Minds are not doctors of medicine, do not practice medicine by any means, do not diagnose or name diseases, do not treat specific conditions or ailments and do not prescribe medication, adjust medication nor practice therapy as prescribed by state law. I understand that hypnosis is a normal and naturally occurring state of consciousness and that through which I will receive beneficial suggestions to motivate/inculcate improvement in my life. I further agree to participate in this program, attending all sessions and performing all suggested exercises to achieve success. If a recording of the self-hypnosis/self-hypnotism/reiki is provided as reinforcement modality, I promise not to, under any circumstances, duplicate, copy, reproduce, sample nor otherwise share said recording with anyone and not to play the said recording in a car or in any motor vehicle at any time. In accordance with all applicable laws, the services rendered are held out to the public as non-therapeutic Hypnotism, defined as the use of hypnosis to inculcate positive thinking and the capacity for self-hypnosis as defined by current state law. None of the practitioners at Self Empowered Minds represent nor provides, nor holds out services as any form of medical, behavioral, or mental health care, psychotherapy, and despite research to the contrary, by law no health benefit claims are made for these services. I also attest and fully understand that this is being done in full accordance and compliance with Local, State & Federal Law and is considered and understood to be in full accordance with said law. I attest here that the information I have provided here is true and accurate to the best of my knowledge. TERMS FOR BIOFEEDBACK SERVICES Terms for Biofeedback Services I understand that the attending practitioners are not allopathic doctors (MDs) and do not portray themselves to be but are providing biofeedback and wellness services. I understand that the services provided identify energetic imbalances. Procedures utilized include stress reduction protocols, nutritional wellness consultation and biofeedback. I fully understand that the attending practitioners do not offer allopathic drugs, surgery, chemical stimulants, or any other conventional treatments. In addition, we do not diagnose, treat or otherwise prescribe for my disease, conditions or illness, or perform any act that would constitute the practice of medicine for which a license is required. I have solicited the attending practitioners’ services in good faith, exercising my free will and following the dictates of my own conscience which allows me to select what I understand is most beneficial to my health. I am fully aware and release the practitioner to do biofeedback testing, wellness consultation and other stress reduction protocols. By signing below I acknowledge that I have read and understand all parts of this waiver, that I had the opportunity to ask any questions with regard to the described procedures, and that I hereby affirm: I am not here for medical diagnostic or treatment procedures and I am here on this and any subsequent visit solely on my own behalf. CANCELLATION POLICY For sessions that are one hour or less that are canceled or rescheduled less than 1 day of the appointment will be charged the full appointment fee. Any session over one hour that is cancelled or rescheduled less than 2 day of the appointment will be charged the full appointment fee. If you have a voucher, you will be charged the full amount of the voucher upon rescheduling. APPOINTMENT REMINDERS We will send you texts and emails as reminders for appointments. Upon receipt, you may choose to opt-out and discontinue any further reminders. IMPORTANT PAYMENT INFORMATION Your appointment is NOT confirmed until Credit card, Voucher or Gift Certificate number is provided. Please call or Text the office at 917-658-1660 to provide the information. At the time of the session, services may be paid by credit card, PayPal, Venmo or cash. Please initial that you have read and understood the terms and policies shown above(Required) WE LOVE SUPPLYING OUR CLIENTS WITH RESOURCES, TOOLS AND OPPORTUNITIES I am interested in the following...(Required) Workshops Virtual Group Sessions One-on-One Sessions I would like to be notified by...(Required) Email Text Social Media Phone Call Not at all SO THAT WE MAY FOCUS ON YOUR INTERESTS.... I'm interested in hypnosis for...(Required) Anxiety/Stress Addiction (Smoking, Drinking, Gambling, Etc) Weight Loss Motivation/Procrastination Mental Clarity Past Life Regression Ancestral Clearing Other No thanks - I'm not interested in Hypnosis Please Specify:I'm interested in Meditation...(Required) Anxiety/Stress Mental Clarity Motivation Other No thanks - I'm not interested in Meditation Please Specify:I'm interested in Biofeedback for...(Required) Emotional Stress Blockages Physical Stress Blockages No thanks - I'm not interested in Biofeedback I'm interested in Reiki for...(Required) Myself My Pet(s) No thanks - I'm not interested in Reiki I'm interested in the following Intuitive Readings...(Required) Coffee Readings Reiki Readings Internal Clarity Readings No thanks - I'm not interested in Intuitive Readings CAPTCHA
