Intake Form

Why Submit this form?

"At Right Minded Strategies we endeavour to provide you with the very best level of service and guidance possible for navigating your road through life ahead."

"The information you provide and submit using our on-line Evaluation Form will will be held in the strictest confidence and save you valuable time during your consultation, enabling us to better prepared and assist your positive outcome - be that through our own professional services or by referring you to another practitioner who may be equipped to better cater to your individual needs."

- Rebecca Evans

Intake FORM - Right Minded Strategies

* Indicates required field

Name *

First

Last

Date of Birth *

Phone Number *

Email *

Street Address *

Are you taking any medication? *

YES NO

...if YES, what is it and why is it prescribed? *

Are you currently seeing another therapist? *

YES NO

Have you had Hypnotherapy before? *

YES NO

Are you a smoker? *

YES NO

Which best describes your alcohol consumption? *

Describe your quality of sleep *

Have you ever suffered from the following? *

Do you suffer from any of the following? *

By submitting this form I hereby declare that I have read and agree to all Terms and Conditions as presented on this web site.

I agree to receiving marketing and promotional materials

Submit

can WE help YOU?

Our sole aim is to improve your life by processes that will help you evaluate and recognise your needs then put in place new levels of ability for you to control self belief, choices and outcomes.

DISCOVERING CHOICE - MOVING FORWARD