Intake form

Name *

Email address *

What services are you interested in?

Please select at least one option.

Hypnotherapy

EFT/TFT

Past Life Regression

What is your main goal for seeking therapy?

Have you previously undergone any form of therapy?

If yes, please specify which type(s):

How did you hear about us?

What is your preferred method of communication?

Please select at least one option.

Email

Phone

Video Call

In-Person

Medical information (doctors name, address, contact number, list any medical ailments and if you are currently seeing a medical practitioner)

Which service or services are you interested in?

Please select at least one option.

Hypnotherapy

EFT/TFT therapy

Past life regression

Tarot readings

Additional questions or comments

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