Client Information Form Often we can help when no one else can. Please complete the form below. Which Practitioner do you Plan to See? Dr. Giles - HypnoCoaching Dr. Bates - Reiki Sessions Both Name * First Name Last Name Email * Phone * Preferred Contact Number (###) ### #### Address * Please indicate your country of residence, even if it is the United States. Address 1 Address 2 City State/Province Zip/Postal Code Country Have you experienced Hypnotism or Reiki before? Yes, I have experienced Hypnotism before. Yes, I have experienced Reiki before. Yes, I have experienced both Hypnotism and Reiki before. No, I am new to this. Goals * What issues are you seeking to resolve? Personal Strengths * What do you believe are your greatest strengths? How did you learn about us? Optional Birth Date Optional MM DD YYYY Pronouns Optional He/Him/His She/Her/Hers They/Them/Theirs Other (please let us know) Relationship Status Optional Single Married Partnered Recently Divorced Recently Widowed Spouse or Partner Name (if applicable) Optional Educational Level Optional * indicates a required field Thank you. Having your intake form on file will make your first session more convenient.
