Mitera Coaching
Book Consultation
GET STARTED
Contact us

Full Intake Form

You’ve taken the first step. This form helps me understand where you are today — physically, emotionally, and energetically — so we can create the most supportive, personalized care plan for you.

CLIENT INFO


Name
Date of Birth
Phone
E-mail
Emergency Contact Name & Phone
Referred By (if applicable)

REASONS FOR VISIT (Check all that apply)


Weight Loss
Anxiety / Overwhelm / Stress
Confidence / Visibility
Sleep Issues / Fatigue
Emotional Regulation
Trauma / Nervous System Support
Energy Work / Reiki
Physical Pain / Tension
Business or Life Coaching
Relationship Support
Others

CURRENT EXPERIENCE


Physical Symptoms You Currently Experience (Check all that apply):

Headaches / Migraines
Digestive Issues / Bloating
Sleep Disruption
Muscle Tension / Body Aches
Chronic Pain
Fatigue / Low Energy
Hormonal Changes
Weight Fluctuations
Cravings / Overeating
Others

Emotional or Mental Experiences You Currently Notice:

Overthinking / Racing Thoughts
Self-Doubt / Low Confidence
Anxiety / Panic
Sadness / Low Mood
Irritability / Anger / Frustration
Difficulty Letting Go / Fear of Change
Emotional Eating / Stress Eating
Feeling Stuck or Frozen
People-Pleasing / Difficulty Saying No
Fear of Visibility / Being Seen
Others

SELF-RATING (Scale 1-10)


How would you rate how you’re feeling today in the following areas?

(1 = struggling | 10 = excellent)

Confidence
Emotional Balance
Energy
Sleep
Stress/Anxiety
Weight Management
Clarity / Direction
Nervous System Regulation (feeling calm/safe in your body)

SUPPORT PREFERENCES


What kind of approach feels most supportive for you?

Gentle and exploratory
Direct guidance with clear steps
Blend of both
I may need help slowing my mind down
I prefer space to share fully
Light structure & accountability

MEDICAL & SAFETY INFORMATION


Are you currently under care of a physician, therapist, or specialist?
Any medical conditions I should be aware of?
Current medications or supplements
Any previous experience with hypnosis, coaching, or energy work?
Any conditions I should be aware of (pregnancy, seizures, mental health diagnosis, etc.)?
Light structure & accountability

CONSENT & SAFETY STATEMENT


I understand that hypnosis, coaching, and energy work are complementary wellness services and not a substitute for medical or psychological care. I acknowledge that my practitioner does not diagnose or treat medical or mental health conditions, and I am responsible for seeking any necessary medical attention as needed.

Signature
Date