Parent(s) | Guardian(s) Name (Required if under 18):
Services Request Information
Please provide a brief description of the current struggle(s) or interests the Client is experiencing/desiring
Please select all that apply to the Client's current struggle(s) and/or interest(s)
Please describe any previous experience with NLP, TIME Techniques, Coaching or Hypnosis
Please describe any behavior(s) and\or emotional issues or interests that you feel may be relevant
In your own words, please describe any significant emotional events during the most recent 3 years
Is the client currently under the care of a physician, psychotherapist, pathologist or licensed medical practitioner for this issue(s)?
If yes, please explain the condition(s) for which the client is being treated and the nature of the treatment(s), including any medications
Please include any additional information which you believe may be relevant to the current struggle(s) or interests
Please describe as clearly as possible the results that you (the client) would like to achieve
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