New Client Intake Form

* Indicates required field

Name *

First

Last

Date of Birth and Age *

Email *

Gender *

Phone Number *

Time Zone *

Full Address *

How Did You Hear About Paige? *

Facebook Internet Search Referral Other

If "Other", please describe how you heard about Paige *

Your education, training and current employment *

Marital or relationship status *

Chief concern *

Have you ever received spiritual counseling or energy healing? If so, please describe the work you did. *

Describe your Family Relationships *

List children's names and ages *

Previous counseling, psychiatric treatment *

Have you ever received hypnotherapy before? *

If "other trauma", please describe. *

Chemical Use *

Have you ever felt the need to cut down on your drinking, eating or using? Have you ever felt annoyed by criticism of your drinking, eating or using? Have you ever felt guilty about your drinking, eating or using? I don't drink alcohol or use substances Substances don't cause a problem in my life

How much beer, wine or hard liquor do you consume each week, on average? *

Have you ever been to rehab or treatment? *

Sexuality - How Would you Best Describe your Sex Life and Sexual Self? *

I feel open, and comfortable with my body and my sexuality I have a lot of shame and guilt about my body and my sexuality I'm not clear about my sexual needs I know what I need and want in terms of sexual intimacy I do not feel comfortable with my sexuality I have poor libido

Money *

I believe I have what I need I don't believe I have what I need I spend every dollar I get I try to save every bit I can I give away money and it flows back to me I believe the Universe will take care of me I have a lot of fear, anxiety and worry over money I am a slave to money and bills

Personal Power *

I can easily make decisions It's hard for me to make decisions I feel comfortable standing in my truth I feel confident in myself I feel a lack of confidence in myself Boundary-setting is easy for me Boundary-setting is hard or even scary for me

Love, Connection, Community *

(I can easily receive love.) EX: When someone says, "I love you" or acknowledges my gifts, I feel touched, grateful, connected (I have trouble recieving love.) EX: When someone says, "I love you", or acknowledges my gifts, I feel shy, embarrassed or uncomfortable I can allow myself to cry Crying is very difficult for me. I can easily say, "I love myself" I can't easily say, "I love myself" I can be proud of myself I can't be proud of myself

Family *

I can be fully myself with my family I have to hide who I truly am with my family My family supports my growth with all its aspects My family doesn't support my growth or differences My family is abusive and critical to me

Lover *

I am in a committed relationship I am not in a committed relationship I can be my true self with my partner It's effortless to be with my partner My partner and I have difficulties communicating My partner and I have difficulties meeting each other emotionally I'm not sure I want to stay with my partner

Friends *

I connect with others easily I have trouble connecting with others I have some true, unconditional friends I don't have any real friends It's hard for me to make friends

Creativity and Visioning *

I love my work and feel extremely satisfied by it I feel my work is lacking in interest and creativity I'm stressed because of my work I have a vision, but I don't know how to move forward I feel something else is waiting for me, but I'm not sure what I am able to satiate my creative side in projects, either at work, or otherwise I don't see myself as a creative person I feel something is missing from my life, but I don't know what

Spirituality and higher purpose - talk freely about your religious affiliation, mystical experiences, feelings, leanings.... How do you use your spiritual path to help you cope with life? *

Is there anything else you'd like me to know about you? *

Insurance Information

What is your Texas Health Insurance Company Name? *

Full Name Listed on Insurance Policy *

Date of Birth *

ID number and Group ID *

YOUR Address Which is Listed on Your insurance Policy *