Intake Form

All information is held strictest confidence.
At no given point is information disclosed or shared without client’s written consent.
You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Last Name

First Name

Home Phone

Mobile

Birth Date

Have you ever been treated for an emotional problem?

Do you have any Allergies?

What would you like to change on your visit?

If you chose another change, what would that be?

What are three strengths you possess?

ACCEPTANCE

I realise that Des Cousens is an educator and an unconscious coach, not a medical doctor or psychologist, and that he cannot diagnose disease, prescribe, or treat medical conditions or serious disorders. I understand that the coaching and training I am receiving from Des Cousens is not a substitute for normal medical care. Additionally, I should continue any present medical treatment and consult my regular physician for treatment of any new or old illnesses. I am willing to be guided through various methods, including Relaxation, Visual Imagery, Creative Visualisation, Hypnosis, Neurolinguistic Programming (NLP), Emotional Freedom Techniques (EFT), and Stress reduction processes for the purposes of vocational or avocational self-improvement. I also agree that Des Cousens or I may terminate this relationship at any time for any reason whatever. I realise that although Des Cousens has considerable training and experience, the training and insights he provides, are not a cure, and I accept that I am paying for his time, expertise, and insights, irrespective of any particular result.

Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Changes Ahead – The Wellspring Warburton, 3424 Warburton Highway. Warburton, Vic 3799 – info@changesahead.com.au – 0477 866 744

All information is held strictest confidence.
At no given point is information disclosed or shared without client’s written consent.
You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.