Intake Form

First/Last Name

Date

Address

City/State/Zip

Email Address

Home Phone

Cell Phone

Date of Birth

Do you have any physical challenges that would interfere with muscle testing? (e.g.: back/neck/arm pain or injuries) Do you have any physical challenges that would interfere with muscle testing? (e.g.: back/neck/arm pain or injuries) No Yes (explain below)

Please explain.

Have you viewed the Rob Williams Psych-K video? Have you viewed the Rob Williams Psych-K video? No Yes

What techniques, processes or therapies you have participated in or experienced to date?

PSYCH-K® Preparation — The two fundamental questions that we ask in PSYCH-K are “how are things for me now?” and “how would I like them to be instead?” The answers to these questions can really illuminate areas in your life where your desires do not match your experience, and the underlying beliefs as to why this may be the case. PSYCH-K is used to modify sub-conscious beliefs from limiting ones to enhancing ones. It allows us to take back control of the part of the mind which is controlling 95% of our lives. Below is a list of common areas of life where people can have issues. Please select which areas you may need help with. PSYCH-K® Preparation — The two fundamental questions that we ask in PSYCH-K are “how are things for me now?” and “how would I like them to be instead?” The answers to these questions can really illuminate areas in your life where your desires do not match your experience, and the underlying beliefs as to why this may be the case. PSYCH-K is used to modify sub-conscious beliefs from limiting ones to enhancing ones. It allows us to take back control of the part of the mind which is controlling 95% of our lives. Below is a list of common areas of life where people can have issues. Please select which areas you may need help with. Grief, Loss and Letting go of past pain Self Esteem and Self Love Relationships – with self, others, giving and receiving Substance abuse, boundaries Spirituality and Trusting God/the Universe Phobias, Fears of People/Places/Thing, Fear of Public Speaking Personal Power Prosperity, Abundance and Money Health and Body

Please list other areas of life that you would like to address, or specific situations you have in mind that you would like to work with.

I understand and agree that I am individually responsible for my own life and it’s unfolding. As an expression of my responsibility I am seeking assistance with the beliefs that manifest my reality, but the actual manifestation of that reality is up to me. I understand and agree that I am individually responsible for my own life and it’s unfolding. As an expression of my responsibility I am seeking assistance with the beliefs that manifest my reality, but the actual manifestation of that reality is up to me. Yes, I agree.