Date of our planned session

Last name

First name

Street and number

Place and postal code

Phone number

Email Address

Date of birth

Relationship status

Occupation

Emergency contact name

Emergency contact phone

Doctor's name and address

Doctor's phone number

Date of last checkup

What medication are you on?

Health problems (past and current)

Please tick areas that apply Please tick areas that apply Addiction (a.o. drinking, smoking, drugs, gambling, compulsive behavior,..) Nervous system state (anxiety, stress, fears, phobias, panic attacks, guilt, relaxation) Food related symptoms (eating problems, food/diet, weight problems, anorexia, bulimia, exercise) Behavior state (depression, confidence, self esteem, motivation, achieving goals, procrastination) Interaction with the world (career issues, interview skills, nerves, public speaking, concentration, exams, memory, driving skills) Sexuality (sexual problems, fertility, IVF, conception, pregnancy, birth) Sensory symptoms (pain control, hearing, sight/vision, mobility, skin problems, hair growth) Relating (relationships, childhood problems, sleep problems)

Confirm you do not have any of the following: Confirm you do not have any of the following: I confirm that I do not auditory/ visual hallucinations, epilepsy, dissociative disorders, personality disorders, psychosis, schizoaffective disorder, schizophrenia.

Please confirm Please confirm I confirm that all the information I provided above is correct and true