INTAKE FORM

Thank you for taking this first step on your journey to a happier, healthier life. Complete the form below so that I can learn more about you.

Participate in my quick and engaging questionnaire designed to provide you with a personalized recommendation that aligns with your individual needs. Whether you are navigating the challenges of anxiety, managing stress, recovering from trauma, or seeking to change certain habits, this questionnaire will help identify the best strategies and resources for you. Discover the support that can make a difference in your journey toward well-being.

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Name *

First

Last

Email *

Birth *

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

I agree to the confidentiality of my responses and personal information.

Marital Status *

Please check all applicable areas of concern from the list below: *

Addictions
Anxiety
Career Issues
Childhood Problems
Chronic Pain
Conception
Confidence
Control
Depression
Eating Disorders
Fertility
Habits
Hearing
Insomnia
Mobility
Motivation
PTSD
Procrastination
Public Speaking
Relationships
Self Esteem
Sexual Health
Sight
Skin Problems
Weight Problems
Other - please specify in the notes
None

Please provide details about any symptoms, triggers, or habits related to the issues you selected *

What issue do you want to address? *

Severe Anxiety, Trauma, or Phobias
Stress, Low Self-Esteem, or Habit Formation
Both

How long have you been experiencing this issue? *

Less than 1 month
1-6 months
More than 6 months

On a scale of 1 to 10, how severe is your issue? *

1-3 (Mild)
4-6 (Moderate)
7-10 (Severe)

How quickly do you want to see results? *

I need rapid change in 1-2 sessions
I prefer a gradual approach over several sessions
I am open to a mix of rapid and long-term support

How much is this issue affecting your daily life? *

It's significantly impacting my life
It's occasionally affecting me, but manageable
It’s not critical, but I want to address it soon

Have you tried therapy before? *

Yes, but with little to no progress
Yes, and I saw some improvement
No, this is my first time seeking therapy

What’s your primary goal with therapy? *

Quick resolution of a deep-rooted issue
Long-term stress management or support
A mix of both immediate results and ongoing care

How comfortable are you with addressing past traumas or deep issues? *

I’m ready to confront these issues head-on
I’m more comfortable with gradual change over time
Open to both approaches

Do you prefer in-person or online therapy? *

In-person only
Online only
I’m flexible with both options

Do you have a specific timeline or event you’re preparing for? *

Yes, I need results quickly
No, I’m focused on long-term personal development
I’m preparing for both short- and long-term goals

What do you want / Magic Wand: If I could wave a magic wand and do one thing for you today; what would it be? What do you want to transform in this session? *

What would your life be like without the problem? *

Has anyone else in your life made you feel badly about yourself? What does this make you believe about yourself? *

What have you said / done in your life that you feel guilt or shame about? What do you judge /criticise yourself for? *

What do you like about yourself? What are you proud of yourself for? *

What qualities, gifts and talents do you have? What do other people say they love about you? *

What do you wish the 'young you' had been told when you were a child? If you could go back in time what would you say to yourself? *

Please provide details of your doctor/GP

Click or drag a file to this area to upload.

Emergency Contact Name *

Emergency Contact Number (please include country and area codes) *

Total Score

$0.00

How provide before?

Recommendation :

RTT session
Clinical Hypnotherapy
Combination package

INTAKE FORM

Recommendation :

Jackie Karkeek

services

exeter

exmouth