Quantum Waves Hypnotherapy & Biofeedback
Change your life one unconscious thought at a time
Call us • 805-704-3599
Search for:
Play or pause music
Home
About
What Is Biofeedback?
Benefits of Biofeedback
Meet Gila
Hypnotherapy
Suggestibility
Relationship Strategies
Integrative Addiction Solutions
Sexual Freedom Hypnosis
Mental Bank
Habit Control
Past Life Regression
Services
Handwriting Analysis
PEMF with iMRS
Quantum Biofeedback (SCIO)
Remote Sessions (SRC)
Packages
Calendar
Testimonials
Contact Us
Request an Appointment
Directions
New Clients
Book Appointment Now
New Client Paperwork
What to Expect
FAQ
Blog
Media/Press
Client Intake Form
Home
→
Contact Us
→
New Clients
→
New Client Paperwork
→
Client Intake Form
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Time of Birth
Place of Birth
*
Home Phone
*
Cell Phone
Email
*
Number of organs removed
(e.g. tonsils, appendix, etc. - count ovaries individually)
Number of prescription or over the counter medications taken daily
Number of times a day you smoke or chew tobacco
Number of steroid type drugs taken in the past year, include inhalers
Number of silver amalgam type dental fillings in current teeth
Number of street drugs used each month
Number of known allergies
Number of persistent thoughts by category e.g.; work, relationship, health issues, etc.
On a scale of 1-100% how much do you feel it is your responsibility for your health
*
Amount of fat in your diet by % (average American diet is at 40%)
Rate overall stress level (1–10 with 10 highest)
Please enter a number from
1
to
10
.
Number. of times a week you exercise 20 minutes or more
Number of alcoholic drinks consumed daily, or average out for week
Number of caffeine products consumed daily e.g.; coffee, tea, Red Bull, etc.
Number of toxic exposures e.g.; CT scan, chemotherapy, radiation therapy, etc.
Number of past injuries emotional & physical – include surgeries
Number of past major infections that required hospitalization or long term medication
Number of glasses of pure water you drink on average per day
Do you feel you are overweight? If so, by how much?
Do you wear a pacemaker?
*
Yes
No
Are you pregnant?
Yes
No
Have you ever had electro-shock therapy?
Yes
No
Signature of client - (parent for minor)
*
Entering you name below functions as a "digital signature".
Name
This field is for validation purposes and should be left unchanged.
New Client Paperwork
Client Intake Form
Consent to Receive Biofeedback Training
Disclosure of Services for Hypnotherapy
Intake Form for Hypnotherapy