NEW CLIENTS FORM Date MM DD YYYY Name First Name Last Name Date of Birth MM DD YYYY Current Age Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Phone Country (###) ### #### Preferred Email Emergency Contact Name and Phone Referred by Current Occupation Marital/Relationship Status Other Persons Currently in Household Past Counseling/Therapy/Hypnotherapy History: (Type and duration) What is your belief in existing beyond our human form? Have you ever attempted suicide? YES NO Are you currently having suicidal thoughts? YES NO Are you currently taking medication? If you are being treated for any medical conditions, what conditions are they? Frequency/amount of Alcohol Usage Frequency/amount/type of other drugs not listed in medications above What questions or concerns are you seeking help with today? Thank you! Cancellation Policy: At least a 24-hour notice is appreciated. Payment: Sessions may be paid through one of the following. If you have Venmo, it is preferred. Venmo @Kim-Kane-5 / PayPal @kimpossiblenow
