Intake Form

DEMOGRAPHICS

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Birth Date(Required)

Gender(Required)

Female

Male

Prefer not to say

Other

Please Specify

Preferred Pronoun(Required)

Please indicate your preferred pronoun

Occupation(Required)

Cell Phone(Required)

Email(Required)

LIFE STYLE

Number of Exercise per week(Required)

Number of cigarettes smoked per day:

Number of Alcoholic beverages per day(Required)

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?

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 indicate

Is 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

Intake Form

DEMOGRAPHICS

LIFE STYLE

SERVICE INFORMATION

BIOFEEDBACK REQUIRED INFORMATION

TERMS FOR HYPNOSIS/REIKI SERVICES

TERMS FOR BIOFEEDBACK SERVICES

CANCELLATION POLICY

APPOINTMENT 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.

WE LOVE SUPPLYING OUR CLIENTS WITH RESOURCES, TOOLS AND OPPORTUNITIES

SO THAT WE MAY FOCUS ON YOUR INTERESTS....

Learn More:

– About
– Blogs
– Youtube Playlist
– Affiliations
– Press
– Privacy Policy
– Important Links

Follow Us:

Explore:

Individual Sessions:

Certificate Training Programs:

– Reiki Usui/Holy Fire I & II Training
– Reiki Usui/Holy Fire Master Training
– Biological Intuitive Master Training
– Reiki Practice Workshops

Group Classes:

Contact Us: (917) 658-1660

Location: 420 E 81ST. SUITE 1 - NY, NY 10028

Company Email: info@SelfEmpoweredMinds.com

Intake Form

DEMOGRAPHICS

LIFE STYLE

SERVICE INFORMATION

BIOFEEDBACK REQUIRED INFORMATION

TERMS FOR HYPNOSIS/REIKI SERVICES

TERMS FOR BIOFEEDBACK SERVICES

CANCELLATION POLICY

APPOINTMENT 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.

WE LOVE SUPPLYING OUR CLIENTS WITH RESOURCES, TOOLS AND OPPORTUNITIES

SO THAT WE MAY FOCUS ON YOUR INTERESTS....

Learn More:

– About– Blogs– Youtube Playlist– Affiliations– Press– Privacy Policy– Important Links

Follow Us:

Explore:

Individual Sessions:

Certificate Training Programs:

– Reiki Usui/Holy Fire I & II Training– Reiki Usui/Holy Fire Master Training– Biological Intuitive Master Training– Reiki Practice Workshops

Group Classes:

Contact Us: (917) 658-1660

Location: 420 E 81ST. SUITE 1 - NY, NY 10028

Company Email: info@SelfEmpoweredMinds.com

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.

– About
– Blogs
– Youtube Playlist
– Affiliations
– Press
– Privacy Policy
– Important Links

– Reiki Usui/Holy Fire I & II Training
– Reiki Usui/Holy Fire Master Training
– Biological Intuitive Master Training
– Reiki Practice Workshops