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Neuro Linguistic Programming
Step 1 of 4 - Personal Information
Date of Birth:
How did you discover our practice and the services we offer?
Do you have any current health concerns?
Please list any operations you have had:
Please note the emotional/mental stresses you have experienced:
e.g. loss of loved ones, major changes, abuse, legal or financial concerns, move of home/school, separation, divorce, others.
What areas of your life would you like to improve?
e.g. Relationships, Work, Health, Pain, Finances, or other, please specify.
Are you presently, or have been under the treatment or a Psychiatrist, Psychologist or Doctor?
If Yes for what condition?
What medications, remedies or supplements do you take and for what condition or illness do you take them?
What emotions would you like to address?
e.g. anger, resentment, fear, sadness, hurts, grief, guilt, jealousy, loss, disappointment, stress or other, please specify.
What are your religious / spiritual beliefs?
What would motivate you to encourage others to benefit from our services?
Desired Outcome (Goal)
How I feel now without it.
How I will feel when I have it.
Ages 0-7 (Imprint)
Ages 8-14 (Modeling)
Ages 15-21 (Socializing)
This field is for validation purposes and should be left unchanged.
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