Intake Form

At Healing in Practice we work with a powerful healing method. This makes it possible to make substantial changes in everyone’s lives.

Although we try to avoid side effects as much as possible, as part of the healing process, suppressed emotions can surface, and (short-term) physical discomfort or restlessness can arise.

By clicking on “Yes, I understand that as a client I remain responsible for my own health.” you declare:

I take the responsibility myself to seek regular medical or psychological help when necessary, or the therapist deems it necessary.

I understand that the treatment is not a substitute for medical treatment or evaluations.

I understand that the therapist cannot be held liable for any side effects, failure to achieve the desired result, or any consequences thereof.

Initials*

First name*

Last name*

Street and number*

Zipcode*

City*

Country*

Email address*

Phone number*

Who is your general practitioner?*

With these anamnesis questions we get a good overview of the complaints, which makes the treatment more targeted and effective. This information will of course be treated confidentially.

Filling in the anamnesis is not mandatory. If you prefer to discuss this in person during the first session, that is also possible.

Marital status

[married, single, cohabiting, divorced]

Profession

[including hours per week]

Age

What prompted your visit?

[What is your main complaint?]

What other complaints do you have?

What has contributed to your complaints in your life?

[In order of importance]

What would you like to achieve with the therapy/treatment?

Have you had any medical care in your life?

[Surgeries, accidents, previous illnesses?]

Are you currently being treated by a doctor/psychologist/specialist?

Do you use any medicines, supplements or other substances?

[If so, which one?]

What do you think of yourself?

[What are your qualities, what is going very well, and what would you like to change?]

How do you feel apart from the complaints?

What does your family situation look like?

[Which people, and age]

What does your sleeping pattern look like?

[What time do you go to bed, do you wake up, do you sleep well?]

Which stimulants do you use?

[Coffee, alcohol, drugs, tobacco? And how often and how much?]

Do you have other habits that require a disproportionate amount of attention, time or money or energy?

[What can you not resist, or is addictive?]

How much do you exercise in a day?

[Do you practice sports? How long and often?]

Do you have any other questions?

[For example, something we should take into account?]

Yes, I understand that as a client I remain responsible for my own health.*

Yes, I agree that the information provided will be stored and processed.* Your data will be treated with care and confidentiality, in accordance with legal obligations.