New Client Form

Dr Kyra's New Client Information Form

(This form will be encrypted in HIPAA compliant format)
Please thoroughly complete this form so that I receive it in advance of your appointment. It will save a lot of time in your first session if I have this information by the day before your session. Past clients have commented about how much they appreciated being able to get right to work in the very first session!
Date

Month Day Year
Date Date Picker Icon
Name

First Name Last Name
E-mail
Date of Birth

Month Day Year
Contact Number:

Area Code Phone Number

Address:

Street Address
Street Address Line 2
City	State
Post Code	Country

Next are 7 open-ended questions to help me get to know you. Don't worry about writing "too much." The more you write the better, so I can help you most effectively.
How did you hear about Dr Kyra, and what prompted you to schedule at this time? Tell me about the issue you want to resolve and the change or improvement you are seeking:
Briefly describe your living situation and who lives in the household. What would you change if you could?
Please tell me about your employment and/or household responsibilities & how you feel about them:
Now it's time for you to tell me about your state of health including energy level, medications, and other therapies/healing programs. If you have specific diagnoses, please list those:
In order to have a holistic view of who you are, it's helpful for me to know a bit about your background & family history, such as how many children were in the family & what your relationship was like with your parents. If you experienced trauma, abuse, neglect, or have confused/unresolved emotions lingering from any experience in your life, mention it here.
What is the single biggest result you would love to have from our work together?
What do you wish you had more of in your life? Feel free to write anything else you think I should know about you:
Terms & Conditions Informed Consent

Dr Kyra does not make medical claims. The educational information and uses we may discuss about hypnotherapy or flower essences do not replace standard medical practices. You should always rely on your own innate wisdom about what the best choices and therapies are for your wellbeing. Except in the case of proven gross negligence or malpractice, you and/or your representatives agree to fully release and hold harmless Kyra Mesich, PsyD from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with your sessions.
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Dr Kyra's New Client Information Form