Rebecca Hufford  - Hypnotherapy, NLP, Transitional and Transitional Coaching,

Experience the Art of Change
 
Contact Us/Intake Form
 
Phone: (503)560-4774
 
 
Serving: Oregon City, West Linn, Gladstone, Milwaukie, Lake Oswego, Tualatin, and Portland
 
FEEL FREE TO ASK ME ANY QUESTIONS OR LEAVE COMMENTS BELOW:
PLEASE COMPLETE THE FORM BELOW AND RETURN IT BEFORE YOUR APPOINTMENT.
DATE:
NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
E-MAIL:
DATE OF BIRTH:
AGE:
DAY PHONE:
HOME PHONE:
CELL PHONE:
EMPLOYER:
EMPLOYER'S ADDRESS (city and state):
GENDER
MALE
FEMALE
MARITIAL STATUS:
single
married
divorced
widowed
IF WIDOWED, NAME OF SPOUSE
NAMES AND AGES OF CHILDREN
WHY ARE YOU SEEKING HYPNOTHERAPY?:
CURRENT HEALTH PROBLEMS:
LIST ANY MEDICATIONS YOU ARE TAKING
DO YOU?:
smoke
use non-prescribed drugs
drink alcohol
RELIGIOUS PREFERENCE:
DO YOU HAVE ANY COMPULSIVE TENDENCIES?:
CURRENT OCCUPATION:
DO YOU ENJOY YOUR WORK?:
WHAT ARE YOUR THREE (3) FAVORITE COLORS?:
WHAT/WHERE ARE YOUR THREE (3) FAVORITE PLACES?:
HOW DID YOU HEAR ABOUT THIS OFFICE?:
Book Life Coaching from Rebecca Hufford in Portland