BRAINSPOTTING SESSION Waitlist
Please complete this form if you would like to remain on my waiting list for a duration of six months. By filling out this form, you have given me permission to make contact with you via the details provided for the referral of counseling services. For information about Hypnotherapy and Brainspotting go to www.groundinghearts.com/rapidchangetherapy
Have you researched or read on the website the benefits of Brainspotting treatment?
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YES
NO
LEGAL FULL NAME
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First Name
LAST NAME
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Briefly share your primary reason for seeking counseling services?
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In the past 6-months, have you had in-patient hospitalization, Intensive Outpatient Program (IOP), Partial Hospital Program (PHP) or terminated a counseling relationship?
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YES
NO
Do you have a personal/family history or have ever been diagnosed with PTSD, Anxiety, Visual/Audio hallucinations or Dissociative Disorder?
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YES
NO
Are you currently taking prescribed medication for a mental health condition?
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YES
NO
Can you sit for a long period of time (15-45 minutes)
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YES
NO
Can you stare for a long period of time (10-45 minutes)
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YES
NO
WHAT DAY OF THE WEEK
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TUESDAYS (10-2, 4-6PM)
WEDNESDAYS (10-2, 5-8PM)
FRIDAYS (10-2, 4-6PM)
SATURDAYS (*by appt only* avail 9-1PM)
This question is important. Do you foresee any future circumstances that may impact/interfere with attending counseling sessions? (For example, changes in work schedule, traveling more than 14 days, moving further away, childcare, medical procedures, legal proceedings) etc.
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YES
NO
Are there any other medication conditions I should be aware of?
Referral (agency, college/university, family/friend member, other)?
Submit
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