Heart-Centered Healing

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Reason for Appointment *

Have you previously received therapy, counselling, coaching, or hypnotherapy? *If yes, please briefly describe:YesNo

Are you currently under the care of a mental health professional? *YesNo

Are you currently taking any medications (including psychiatric medications)? *If yes, please list the medication(s) and purpose:YesNo

Have you ever been diagnosed with a mental health condition? *If yes, please specify:YesNo

What are your expectations from therapy/coaching sessions at Healing Atrium? *

What would positive progress or success look like for you? *

Preferred mode of session: *OnlineIn-person (if available)Hybrid

Preferred days & time slots: *

Healing Atrium does not provide emergency or crisis services.

If you are currently experiencing thoughts of self-harm, suicide, or feel unsafe, please contact your local emergency services or a crisis helpline immediately.

Do you confirm that you are not in immediate crisis at the time of submitting this form?YesNo

Please read carefully and confirm: *I understand that hypnotherapy, psychotherapy, counselling, and life coaching are professional support services and do not replace medical or psychiatric treatment.I understand that results vary from person to person and no guarantees are made.I confirm that the information provided is accurate to the best of my knowledge.I understand that all sessions are confidential, except where disclosure is required by law for safety reasons.

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