New Client Intake Form
Please complete this form with as much detail as you can and submit prior to your session. Your information is important to me and will be held in the upmost confidence. However at the this stage in my training I am required to share session notes and forms with my Mentor and examiner (only).
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Age
*
What do you wish to achieve from working with BodyTalk and me?
*
What are you current main health concerns? (Body, Mind or Spirit)
*
Please briefly tell me your medical history (injuries | accidents | surgeries etc.)
*
Are you currently seeing any healthcare professionals?
*
How are you sleeping? (How many hours, quality etc.)
*
Please read the list and tick any that you are currently feeling or have felt over the last 3 months
*
Criticised
Overwhelmed
Apprehensive
Uncertainty
Agitated
Paranoid
Intolerant
Muddled
Guilty
Overworked
Aggravated
Paralysed
Depressed
Rejected
Easily Irritated
Persecuted
Helpless
Anxious
Hopeless
Uneasy
Sad
Depressed
Grieving
Abused
Fearful
Unable to Grieve
Distress
Impatient
Angry
Worried
Outraged
Sleepless
Nervous
Restless
Intimidated
NONE
Do you have any concerns about the following areas - please tick and comment below
Digestion
Respiratory
Cardiovascular
Urinary
Nervous System
Muscle / Joints
Lymphatic System
Endocrine System
Please give further details in relation to any areas ticked above or ANYTHING else you feel I should be aware of.
Please take a moment to consider the following.
*
Zero
Minimal
Moderate
High
My family stress is
My relationship stress is
My work stress is
My financial stress is
My health stress is
Please take a moment to consider how much time you have for each of the following.
*
Zero
Minimal
Moderate
High
'ME'
Exercise
Relationship (s)
Meditation
Social
Would you like to go on my mailing list. No spam! Just updates and inetrests.
Yes
No
How did you hear about me
Bugle
Memo
Friend
My Website
New Zealand BodyTalk Facebook
Other
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