Date of Birth
How did you hear about Mindful Impact?
Client or Physician Referral - their name
Primary Goals (tick all that apply)
How long have you had this issue/problem?
What is your priority goal for this session today?
Are you ready to make the changes necessary to address this goal?
Do you have a primary care physician?
Doctor's full name
Name of medical practice
Address of Practice
Practice Phone Number
List any current health matters of concern:
List any medications you are taking:
Please briefly share anything else that would be helpful to know about you, (i.e., recent life-changing events such as deaths, divorce, job changes, health issues, past trauma etc.):
Are you currently suffering from any of the following (tick all that apply):
List any other matters that are negatively influencing you:
List your three favourite places to be (e.g. beach, forest, snow, city etc.):
When on holiday do you prefer relaxation or excitement?
What is currently your most important life goal?