Get Initial Intake Form - Debbie Nesbitt

The Initial Intake Form - Debbie Nesbitt is a crucial document for establishing your care with NW Medical Hypnosis, LLC. This guide offers clear, step-by-step instructions on how to complete the form accurately and efficiently, ensuring that all necessary information is provided.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your online editor.
2. Begin by entering your client name in the designated field.
3. Next, fill in the date of completion, ensuring it reflects the current day.
4. Provide your complete address, including city, state, and zip code, in the respective fields.
5. Enter your home phone number, along with your cell and work numbers in the specified areas.
6. Indicate your marital status by selecting one of the options available (single, married, partnered, divorced, or widowed).
7. Fill in your date of birth in the format of month/day/year.
8. State your occupation and the number of children you have.
9. List the people residing in your household.
10. If applicable, share your religious or spiritual preferences.
11. Complete the emergency contact section, including their relationship to you and their phone number.
12. Provide the names and contact information for your primary care provider and any psychologist or counselor you may have.
13. Indicate your previous experiences with various therapies and modalities by checking the relevant options provided.
14. State how you learned about NW Medical Hypnosis, LLC, selecting from the provided options.
15. Specify if you would like to receive the monthly newsletter and periodic updates by marking 'yes' or 'no'.
16. Articulate the reason for your visit, along with your desired outcome, in the provided text fields.
17. Indicate if you are currently experiencing or have a history of specific conditions by marking the relevant options.
18. List any medical or psychological conditions for which you are being treated.
19. Detail all medications, including herbal and vitamin supplements, in the medication section, noting the dosage and frequency.
20. Review your form for completeness and accuracy. Once satisfied, you can save changes, download, print, or share the form as needed.

Complete your Initial Intake Form online today to begin your journey with NW Medical Hypnosis, LLC.