Dynamic Mind Institute

Intake Form

Date:  _________________________ Appointment Time:  ______________

First Name:  _________________________________________________________

Last Name:  _________________________________________________________

Street:    ____________________________________________________________

City:      ____________________________________________________________

State:     ___________________________

Telephone:  ______________________________________

E-mail:        ______________________________________

What do you want to work on?:   _________________________________________

How did you hear about us?:    _________________________________________

Birthday:   _____________________

Age:           _____________________

Male:         Female:                

Married:  Single:   Divorced:  Partnered:   Widowed:

Children:   _____________________

Health Problems and Medications:   __________________________________________

Grade Completed:  _____ College Years Completed:   _____Major: ________________

Goals:  _________________________________________________________________

            _________________________________________________________________

           __________________________________________________________________