Testimonials of anxiety relief, stress reduction, powerful holistic healing by Jessica Lin, Maryland, Virginia, Washington DC

CONFIDENTIAL CLIENT INTAKE

Welcome to Jessica Lin Mind-Body Healing and Hypnosis. Please fill out this form carefully in order to make best use of our session time together. Information submitted is kept strictly confidential.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Date of Birth (mm/dd/yyyy) *

Occupation *

Highest Education Obtained *

How did you hear about Jessica Lin Healing and Hypnosis? *

Currently under a medical doctor's or a mental health professional's care for: *

Please describe your current challenges (physical, mental/emotional, or spiritual): *

List 3 goals you wish to achieve from the sessions: (Please number each item) *

How would life be different and better when you have reached the above 3 goals? (Please be specific) *

Describe one of your favorite scenes or places which symbolize good feelings, such as peace, harmony, tranquility, happiness, or relaxation. Be sure to focus on the senses, (e.g., pleasant scent, breeze, warmth of sunlight) evoked by the scene: *

Submit Form