Intake Form | Tender Empowerment

Name*

Best Phone Number To Be Reached At*

Alternate Phone Number

Emergency Contact*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Birth Date*

Occupation

Please list family members you are currently living with

General Reason For Your Visit*

Have You Been Seen For This Issue By Anyone

Have You Seen A Hypnotherapist In The Past

Who Is Your General Physician?

Please List Any Medication You Are Currently Taking

Please Check All That Apply

Health History

Please check all that you have been treated for in the past

Please list any phobias

Please list any places that you are afraid of or uncomfortable with

Anything else you would like to share?