Intake Form This record is confidential "*" indicates required fields PERSONAL - Voluntary InformationName First Last Email PhonePurpose of SessionReferred byDate DD slash MM slash YYYY Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code What is your gender? Female Male Non-binary Transgender I prefer not to say HeightWeightBirth Date MM slash DD slash YYYY FAMILYMarital StatusPlease selectMarriedSingleDivorcedSeparatedCommon-law partnerI prefer not to sayName of partnerChildrenParentsOther family informationEDUCATIONLast School AttendedGrade CompletedGENERAL HEALTHHave you ever been diagnosed with mental illnesses? ExplainAilmentsAllergiesMedicationsSurgeriesHabits Alcohol Tobacco Coffee / Tea Special Diet Please describe the special dietFAMILY HISTORYPlease describe any relevant family historyFamily PhysicianLast visit MM slash DD slash YYYY Are you in general good health?Are you presently in any physical discomfort?If you have or have had any of the following, please check: Cramps or numbness Eye Trouble Diabetes Ear Trouble Kidney Trouble Heart Trouble Rheumatic Fever Tuberculosis High Blood Pressure Liver Trouble Asthma Blood Disease PERSONAL GOALSObjective #1Objective #2Objective #3Objective #4Additional commentsSelect the areas that are affecting you: Aggression Alcohol Amnesia Anger Audio Reminders Avoidance Children Compulsions Concentration Confusion Denial Dreams Drugs Eating habits Excess worrying Fatigue Fears Flashbacks General health Grief Guilt Illusions Intrusive thoughts Kinesthetic reminders Lack of interest Memories Mental replaying Negative or no future Numbing On guard Relationships Sadness Self Blame Self-Esteem Shame Sleep Visual reminders CONSENT & AGREEMENTSConsent* I understand that it will be required of me to take into account any mental or physical vulnerability, or weakness, that my body has and I will inform Lynne Cardinal of any particular issue that may affect the sessions. I understand that each session is tailored to my needs and will be adapted respectfully. If hypnosis is part of the services requested, it is important to understand that the hypnotists help to position me in the driver’s seat, to regain control. For hypnosis to work, one has to understand the process and do the session with an open mind. Hypnosis is an effective way to achieve your goals.*Consent* I free Lynne Cardinal from any responsibility related to all sessions provided, to all exercises done during the hypnosis, meditation or coaching sessions.*Consent* I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment of prescribing of medicine for any disease, or any licensed and controlled act which may constitute the practice of medicine.*Consent* I agree to the Cancellation Policy: Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in our schedule that could have been filled by another client. As such, we require 24 hours’ notice for any cancellations or changes to your appointment. Clients who provide less than 24 hours’ notice will be charged a late cancellation fee of $60. Clients who miss their appointment, will be charged a missed appointment fee of the full-service fee.*Consent* This statement is being signed voluntarily. All sessions including the prepaid packages are non-refundable but the prepaid packages can be shared, at our discretion.*CAPTCHA