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Client Intake Form

Please tell us a little bit about your Insomnia.

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Question 1 of 6

1. What are you struggling with? (You may choose multiple) 

(Select all that apply)
A

Falling Asleep

B

Racing Thoughts

C

Anxiety about sleep

D

Staying Asleep through the night (Multiple Awakenings)

E

Waking up earlier than I want

Question 2 of 6

     2. How long have you been struggling with insomnia? 

A

Less than 3 months

B

3-6 months

C

6-12 months

D

1-2 years

E

2+years

Question 3 of 6

3. Are you having any challenges with the following? ( you may choose multiple)

(Select all that apply)
A

Productivity/Work

B

Mood

C

Energy Levels

D

Increased stress, anxiety, and or depression

E

Postponing or cancelling activities

Question 4 of 6

4. Do you currently do any of the following to fall asleep? (You may choose multiple)

 

(Select all that apply)
A

Take supplements

B

Take prescription medication

C

Exercise

D

Meditate

Question 5 of 6

How did you hear about us?

Question 6 of 6

Additional Comments: Please share additional information.

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