Platinum Mind Therapy Booking

Platinum Mind Therapy Booking Form

CONFIDENTIAL

PERSONAL INFORMATION

Full Name *

Date of Birth *

Gender *MaleFemaleNon-binaryPrefer not to say

Street Address *

Apartment, suite, etc

State/Province

ZIP / Postal Code

Email *

Phone Number *

Preferred Method of Contact *PhoneEmailSMSWhatsApp

Emergency Contact Name & Relationship *

Emergency Contact Phone Number *

Are you currently receiving treatment from any healthcare professional (GP, therapist, psychiatrist, etc.)? *YesNo

Please give details *

Are you currently taking any medication? *YesNo

Please specify *

Please elaborate *

Have you ever had hypnotherapy, EMDR, psychotherapy, or counselling before? *YesNo

what was the outcome? *

Occupation/Profession *

How would you describe your lifestyle? (e.g., high stress, active, sedentary) *

Do you use any recreational substances including alcohol? If so, please elaborate, how much and how often? *

Sleep Pattern (hours per night, quality) *

Exercise Frequency *Rarely1–2 times/week3–4 times/weekDaily

What brings you to Platinum Mind Therapy? *(Please describe your main issue or goal for therapy.)

When did this issue first begin? *

What have you tried so far to address it? *

What impact is this issue having on your life (personal, professional, emotional, physical)? *

On a scale of 1–10, how committed are you to resolving this issue or improving this area of your life? *1 (Not at all)10 (Fully Committed)

What do you hope to achieve through working with me? *

Client Signature *

Date *

For Practitioner Use Only Initial Observations / Notes: