Mindful InnerChange Intake Form - Mindful InnerChange

Personal Information:

Name *

First

Last

Date of Birth *

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

If this client is a Minor, please the following:

Parent/Guardian Name

First

Last

Parent/Guardian Email

Parent/Guardian Phone

Service(s) of Interest:

Upon initial interview and assessment more services may be recommended in combination for achieving a specific goal and enhancing your healing process.

Check each service you are interested in.

Hypnotherapy

Have you experienced or currently practice any of the above?

Yes
No

Which ones of these do you practice or have experience in?

What was your reason/interest in these practices, how often have you done them, and what were your results?

Any injuries or physical conditions I should be aware of?

Medical History:

Are you currently under the care of a doctor?

Yes
No

Name of Doctor

Medications, if any:

Are you currently under treatment of a counselor or therapist?

Yes
No

Name of Counselor/Therapist

Medications, if any:

Concerns or Interests:

Check what you feel applies to you.

Any Fears or Phobias

Describe your fears/phobias.

Other

Describe any other concerns or interests:

Life Events:

Check what you experienced in the last 12 months.

Describe any other life events you have experienced:

Agreement and Disclaimer:

I agree to participate in the healing process and I realize it is not psychotherapy or a replacement of psychotherapy. I take full responsibility for consulting with a medical doctor or therapist regarding any concerns about my participation. I agree to hold Mecca Wagner-Brown harmless for any complications resulting from this work.

Entering your name in the "Client Signature" box below will serve as your signature and you are acknowledging that you agree to participate in this process with full understanding and personal responsibility.

Client Signature *

Date *

Disclaimer: Mecca Wagner-Brown dba Mindful InnerChange does not provide medical diagnosis, or consultations related to health, medical or psychiatric issues; nor does it serve as substitute for medical or psychological diagnosis and treatment. It is recommended you see a licensed physician or licensed healthcare professional for any physical or psychological ailments you may have.

By utilizing the services and information provided by Mecca Wagner-Brown, you acknowledge and agree to fully release, indemnify, and hold harmless, Mecca Wagner-Brown, and others associated with Mindful InnerChange, from any claim or liability whatsoever, including without limitation, direct or indirect, special, incidental, compensatory, exemplary or consequential damages, losses or expenses.

Any information, stories, examples or testimonials presented on the Mindful InnerChange website do not constitute a warranty, guarantee, or prediction regarding the outcome of a treatment with Mecca Wagner-Brown. You may not disseminate, modify, copy, in whole or in part, such copyrighted material unless specifically permitted to do so by Mecca Wagner-Brown (dba Mindful InnerChange). By continuing to explore this website, or choosing to respond with and receive any services from Mindful InnerChange, you agree to all of the above.

Check this box to acknowledge you have read the agreement and disclaimer above.

I agree.