LEEL Therapy Intake Form

First Name

Last Name

Email Address

Birthday

Month

Day

Year

Address

Phone

Relational Status

Occupation

Doctors Name

Doctors Address

Date last Check up that you remember?

Current Medication being taken?

Emergency Contact Name

Emergency Contact Number

Medical and Wellbeing History

Previous medications (please include any antidepressant, antipsychotic medications as well):

Health issues (past and present):

Previous and current mental health issues:

Do you currently have, or have you previously had, any of the following

Group 8: Select All that Apply to You

Relationships

Childhood Problems

Sleep Problems

Briefly describe the issue, challenge, symptom, or concern for which you are seeking help for:

What triggers this problem/issue? What are the symptoms—both physical and mental? How would you describe the characteristics of this problem?

Briefly describe your childhood and family background, including your siblings and the age 3 differences between you.

What outcome do you hope to achieve through this session? IF I HAD A MAGIC WAND AND COULD GRANT YOU ONE WISH DURING YOUR SESSION WHAT WOULD THAT BE? (Be as specific as possible.)

What would your life be like if this problem were resolved? What would you do differently? What could you achieve and accomplish? How would you feel in your own skin? Please use only positive words and affirming statements.

How will you know if our session has worked? Please describe what that would look or feel like for you.

Client Declaration

I confirm that I have completed the client intake form accurately and to the best of my knowledge. I understand that I am fully responsible for the sessions outcomes and for maintaining my own physical and

emotional health and well-being. I acknowledge that the success of the process requires my active participation, including consistently listening

to my personalised recording daily for a minimum of 21-28 days. I understand that it is entirely my choice whether to follow these recommendations.

Cancellation Policy

Appointments cancelled with less than 48 hours’ notice will be charged in full. By ticking below, I confirm that I have read, understood, and agreed to these terms and conditions.

I agree with the terms and conditions of LEEL Therapy Terms and Conditions | GDPR