Consultation form

First name

Last name

Email

Address

Date of birth

Day

Month

Year

Doctor's name & phone number

Please list your medical conditions here (please include psychiatric diagnoses)

Previous experience with therapy or hypnotherapy

Do you smoke? If so, how much and for how long?

How much caffeine do you ingest per day?

How often do you consume alcohol?

less than once a week

a few times per week

almost daily

How often do you exercise

less than once a week

a few times per week

almost daily

Please describe your sleep

What is bringing you to therapy?

What triggers the issue you are having?

Impact on your life (work, relationships, in general)

Coping mechanisms - what makes it better or worse?

What do you think caused it?

What do you think cause the problem to continue?

Treatment goals

I declare that the info provided is accurate and complete.

I understand that my data will be held confidentially. If I present as a danger to myself or others, I give Tara the right to assist me in protecting myself/others.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

By signing this form, you give permission to Tara Yoga & Wellness to store your data safely and securely. Tara Yoga & Wellness takes all necessary measures to protect your personal information, and the information that you provide is confidential. For more information on our terms & conditions and GDPR privacy policy, please click on the tabs on the bottom right side of this website.