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MCAR - Italy
Master Creators Academy
Our Team
Lia Dunlap
The Master Creators Guild
Please take a few minutes to complete the following Executive Level Application. This will ensure that we can jump right to work when we meet. The more detailed you can be about your responses the better.
Client Intake Form
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Name
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First
Last
Name I like to be called
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Email
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Primary Contact Number
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Alternate / Work Phone
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Where you referred, if so by whom?
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First
Last
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Address
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City
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Zip Code
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Date of Birth (MO/DY/YR)
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Gender
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Male
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Marital Status
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Married
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Occupation
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Current Income
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Less than $10,000
$10,001-$25,000
$25,001-$40,000
$70,001-$100,000
> $100,000
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Have you ever been treated for an emotional problem?
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Yes
No
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If yes, please explain:
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Have you ever been hypnotized before?
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Yes
No
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If so, what for?
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Do you have any fears or phobias?
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Yes
No
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If yes, please explain:
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What do you want to accomplish through your work and use of The POWER Plan program, Coaching or Hypnotherapy?
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Any previous efforts to solve this problem?
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Yes
No
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If yes, please explain:
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How did you hear about us?
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Medical Referral
Friend/Relative
Internet Search
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Other
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If other, explain:
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By stating I Agree and signing below, I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for the treatment of any new or old illnesses.
Select Agreement Option
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I Disagree
Electronic Signature: Enter Full Name
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