Intake & Consultation form

Intake & Consultation form

Rapid Transformational Therapy by Dr Lahvenya
Name

First NameLast Name
Preferred name
Date of birth & Age
Marital / Relationship status
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
- Medical history / concerns
- Doctor's name & address
- Date of last check up ?
- Medications & drug history
- AddictionAlcoholSmokingGamblingCompulsive behaviourAnxietyStressFearsPhobiasPanic attacksGuiltRelaxationEating problemsFood & dietWeight issuesAnorexiaBulimiaExerciseDepressionSleeping disordersConfidenceSelf esteemMotivationProcrastinationAchieving goalsCareer issuesNervesInterview skillsPublic speakingConcentrationsExamsMemoryDriving skillsSexual problemsFertilitySexual problemsIVFConceptionPregnancyBirthPain controlVision/ sightHearingMobilitySkin problemsHair growthRelationshipsChildhood problemsSleep problems
- What is SINGLE the most important issue that would like to address with in this session ?
- Describe your childhood in general, anything relevant. ie relationship with parents, siblings & family dynamics.
- If I had a magic wand, what would be the one vital thing you would love to solve in one session?
- Life Without the Problem - What would your life look like without the issue (use strong, powerful, descriptive words) Be specific what would you love to feel, hear, see. How would your day be ?
- In a scale 1 - 10 what is the level of your commitment to make lasting change in your life (main issue).
- Should be Empty: