Client Intake Form

Your Name/Your Business Name

Contact Number

Email

Website URL

Personal Information

First name

Last name

Year of Birth

Email

Address

Emergency Contact Name:

Emergency Contact Phone

Health and Wellness Background

Please describe your current health condition and any medical diagnoses you have received:

Are you currently taking any medications or supplements? If yes, please list them:

Have you been diagnosed with or are you currently experiencing any of the following conditions? (Check all that apply)

Please describe any past or current treatments you have tried for your condition(s):

Do you have any allergies or sensitivities (food, environmental, etc.)? If yes, please describe:

Lifestyle and Habits

Describe your current daily routine (work, exercise, leisure, etc.):

How would you rate your current stress levels? (1 being very low, 10 being very high)

How many hours of sleep do you get on average per night? Do you experience any sleep difficulties?

What does your diet typically consist of? Please note any specific dietary restrictions or preferences:

Do you engage in any relaxation or mindfulness practices (e.g., meditation, yoga, deep breathing)? If yes, please describe:

Goals and Expectations

What are your primary goals for participating in the Gupta Program?

What specific symptoms or issues are you hoping to address through this program?

What would you consider a successful outcome from participating in this program?

Are there any specific areas of the Gupta Program that you are particularly interested in or have concerns about?

Support and Accountability

Do you have a support system in place (family, friends, healthcare providers) to help you through this program? If yes, please describe:

How do you prefer to receive support and communication during the program?

Additional Information

Is there anything else you would like to share about your health, lifestyle, or expectations that will help us tailor the program to your needs?

Consent and Agreement

By completing and submitting this form, you agree to participate in the Brain Retraining Program under the guidance of

Your Name/Your Business Name

You understand that this program is not a substitute for professional medical advice, diagnosis, or treatment.

Client's Signature

Date

Shonna Stokowski