New Client Intake Questionnaire

This form is not optimized for mobile devices – it is recommended you submit this information using a laptop or PC.

Please note – although the information you provide here is kept in the strictest confidence by my office, this form is not digitally secure. By completing this form online, you are indicating your understanding and agreement.

If you prefer to submit a more digitally secure form, please download the form below, complete it and, and email to jen@jenmerkelhypnosis.com.