(309) 518-9333

Intake Form PSP Session

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Instructions (optional)

Welcome to my short intake form! All answers are confidential.

Name

Email Address

Phone Number

Are you over 18?

Yes

If you have any physical or mental health diagnoses, are you under the care of someone with the correct license to treat that condition?

Yes I have licensed healthcare for my diagnosis

No I don't have licensed healthcare for my diagnosis

I don't have any diagnoses

What are we working on?

Describe the change you seek to create

Describe how you'll be feeling on the other side of this change

What, if any, are your spiritual beliefs?

What, if any, is your experience with the PSP? Do you have any certain inductions or approaches that you know work well?

How many sessions are you booking?

1 session ($200)

2 sessions ($400)

3 sessions ($500)

6 sessions ($1000)

I'll send you a PayPal invoice

Scheduling (optional)

Tuesdays at 10am CST

Tuesdays at 12pm CST

Tuesdays at 2pm CST

Tuesdays at 4pm CST

Thursdays at 10am CST

Thursdays at 12pm CST

Thursdays at 2pm CST

Thursdays at 4pm CST

Thursdays at 6pm CST

Fridays at 10am CST

Saturdays at 10am CST

Saturdays at 12pm CST

If we haven't already scheduled, select up to 3 and I'll get back to you to confirm one.

Confidentiality, Self-Responsibility, Cancellation Policy

I agree to the terms and conditions

Signature

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law

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URL

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