The Flow Reset Method™ Intake Form | Find Your Flow Healing

Full Name*

Date of Birth*

Email*

Address*

Phone Number*

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relationship*

1. What brings you to Find Your Flow Healing at this time?*

2. How long have you been experiencing this issue?*

Less than 3 months

3-6 months

6-12 months

1-2 years

More than 2 years

3. What feelings or symptoms are you currently struggling with? Select all that apply.*

Anxiety

Depression

Anger/ irritability

Overwhelm/ stress

Grief/ loss

Fear/ phobias

Low self-esteem

Guilt/ shame

Feeling stuck/blocked

Sleep issues

Pain (physical or emotional)

Social/ Performance Anxiety

Feeling flat often

PTSD

OCD

People pleasing behaviour

Self doubt/ imposter syndrome

Procrastination

Unwanted habits

Difficulty letting go

Enter any other feelings or symptoms here:

4. On a scale of 1-10, how much is this currently affecting your daily life?*

1 = minimal impact

2

3

4

5

6

7

8

9

10 = severely impacting everything

5. Have you experienced hypnotherapy before?*

No

Yes - please provide details:

What type of hypnotherapy?

How many sessions?

Was it helpful?

6. Have you tried any other therapies or treatments for this issue?*

No

Yes

If yes, please list them and briefly describe how helpful they were:

7. What would you like to achieve through our sessions together?*

8. On a scale of 1-10, how ready do you feel to make changes in your life right now?*

1 = just exploring

2

3

4

5

6

7

8

9

10 = I'm all in and ready to commit

9. Do you have any current medical conditions?*

No

Yes

Please provide details of any current medical conditions

10. Are you currently taking any medications (including over-the-counter, CBD & THC)?*

No

Yes

Please list medication names and what they're for

11. Have you ever been diagnosed with a mental health condition?*

No

Yes

Please provide details (diagnosis, when, current treatment)

12. Do you have a history of any of the following? (Please check all that apply)*

Seizures

Epilepsy

Psychosis

Dissociative disorders

Severe trauma (currently unmanaged)

None of the above

If yes to any, please provide details

13. Are you currently working with any other healthcare providers?*

No

Yes

If yes, please list (e.g., GP, psychologist, psychiatrist, counselor)

14 a. Alcohol*

Never

Occasionally (1-2 times per week)

Often (3-5 times per week

Daily

14 b. Cigarettes/Vaping:*

Never

Occasionally

Often

Daily

14 c. Recreational drugs:*

Never

Occasionally

Often

Daily

If you use any substances, please specify which ones:

15. How often do you exercise?*

Never

Occasionally (1-2 times per week)

Often (3-5 times per week)

Daily

If yes, what type of exercise?

16 a. How would you describe your sleep quality?*

Poor (rarely sleep well)

Fair (sometimes sleep well)

Good (usually sleep well)

Excellent (consistently sleep well)

16 b. Do you take any supplements or medications for sleep?*

No

Yes

If yes, please specify

Average hours of sleep per night:*

17 a. How would you describe your digestion? (Select all that apply)*

Regular and healthy

Sluggish

Sensitive

Bloating

Reflux/heartburn

Constipation

Diarrhea

Alternating constipation/diarrhea

17 b. Have you been diagnosed with IBS or other digestive conditions? *

No

Yes

If yes, please specify

18. Do you experience nausea or stomach upset when stressed?*

Never

Occasionally

Often

Always

19. How often do you experience gut-related issues?*

Never

Occasionally

Often

Daily

20 a. Do you work?*

No

Yes

If yes, what do you do?

20 b. How do you feel about your work?*

21. What activities or hobbies do you enjoy?

22. Are You Spiritual or Religious?

No

Yes

If yes, does this play a role in your healing journey?

23. How did you hear about Find Your Flow Healing?*

Google search

Instagram

Facebook

Friend/family referral

Another practitioner

Other

Please share name of referral, practitioner or other if applicable:

24. Is there anything else you'd like me to know before we meet?

PLEASE READ CAREFULLY AND TICK TO CONFIRM YOU UNDERSTAND:*

I understand that hypnotherapy is not a substitute for medical treatment or mental health care. I will continue to work with my GP and/or mental health professional as needed, and I will inform them of my hypnotherapy sessions.

I understand that all information shared is confidential*

Except in circumstances where: There is risk of harm to myself or others. There is disclosure of child abuse or neglect. I provide written consent to share information. Information is required by law.

I consent to hypnotherapy treatment and understand:*

That I can pause or stop a session at any time if I feel uncomfortable.

I understand the cancellation policy:*

A minimum of 24 hours notice is required for cancellations or rescheduling. Late cancellations (less than 24 hours) will be charged at the full session rate. Exceptions may be made for genuine medical emergencies or exceptional circumstances.

I agree to use the Vagus Nerve Stimulation device as safely and understand*

I acknowledge that I have been provided with a vagus nerve stimulation device and agree to use it strictly as instructed, not alter settings unless directed, cease use if adverse effects occur, disclose relevant medical conditions, and accept full responsibility for its use outside of supervised sessions.

Client Commitment to the Process*

I understand that the effectiveness of this work depends on my active participation and consistency, and I agree to engage fully in the process, including attending sessions and completing any recommended practices. I acknowledge that results are not guaranteed and are influenced by my level of commitment, and I accept responsibility for my progress.

The Flow Reset Method™–
Intake Form

Connect & Find Your Flow

The Flow Reset Method™–Intake Form

Connect & Find Your Flow

The Flow Reset Method™–
Intake Form