Intake Form

Relaxation and Guided Imagery Session

All information on this form is confidential. 

Name:

Address:

Email:                                                         Phone number:

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Health:

Do you have any current health conditions?  Please give brief details

Are you taking any medication?

Have you ever been referred for psychiatric treatment?

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Relaxation:

What kind of things do you do to relax in your day to day life?

How is your sleep?

Do you have any favourite places you like to be, places you find restorative?

Do you have any thoughts about the kind of imagery you would like to hear in the session?

Are there any images you do not want included?  Perhaps they bring unpleasant feelings, you have a fear of them e.g. birds, darkness, or they irritate you in some way.

Declaration:

The information on this form is accurate to the best of my knowledge.  I understand that the sessions are for the purpose of relaxation.

Signed:                                                                                                Date: