Client Information Sheet

Name: *

First

Last

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Age:

DOB

Address:

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Phone:

Email: *

Employer:

Occupation:

Other Family Member’s Names:

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Gender:

Age:

Member #2:

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Gender:

Age:

Member #3:

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Gender:

Age:

Member #4:

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Gender:

Age:

Member #5:

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Gender:

Age:

Emergency Contact* (By listing this person you give permission to contact them in the event of an emergency. *

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Relationship to Client:

Phone:

Reason(s) for seeking services:

Others:

Specific desired goals or concerns for which services are desired:

How long have you been experiencing the above concerns and what were the circumstances when you first realized you were having this experience?

On a scale of 0-10 with 0 = “Not At All” and 10 = “Extremely”, how committed are you to getting to the heart of the matter so you can be free from the unpleasant experiences?

Selected Value: 0

What behaviors and habits do you currently engage in that you believe support your Well Being?

What behaviors and habits do you currently engage in that you believe inhibit your experience of health and mental wellbeing?

List all the people you know that will sincerely and consistently support you with the beneficial changes you will be making?

Personal & Professional Development

Performance Training & Neurotherapy

Before you get started!