Intake Form

All information is held strictest confidence.
At no given point is information disclosed or shared without client’s written consent.
You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

First Name

Last Name

Mobile

Age

Current cup size

Preferred cup size

Do you have any current injuries or problems on arms, hands, shoulders or neck ?

Yes No

Have you ever been in hypnosis ?

Yes No

Have your breasts ever been bigger ?, and when ?

On a scale from 1 to 10, how happy are you with your body in general ? (10 - being extremely happy)

What part of your body do you like least ?

What part of your body do you like best ?

Why do you want bigger breasts ?

What would be different for you if you had bigger breasts ?

Can you imagine yourself with big breasts ?

Yes No

Do you have a current medical problem ?

Yes No

Have you or have you ever had problems with endometriosis ?

Yes No

Do you suffer from some hormonal defects ?

Yes No

Have you ever taken hormonal supplements ?

Yes No

ACCEPTANCE

I realise that Des Cousens is an educator and an unconscious coach, not a medical doctor or psychologist, and that he cannot diagnose disease, prescribe, or treat medical conditions or serious disorders. I understand that the coaching and training I am receiving from Des Cousens is not a substitute for normal medical care. Additionally, I should continue any present medical treatment and consult my regular physician for treatment of any new or old illnesses. I am willing to be guided through various methods, including Relaxation, Visual Imagery, Creative Visualisation, Hypnosis, Neurolinguistic Programming (NLP), Emotional Freedom Techniques (EFT), and Stress reduction processes for the purposes of vocational or avocational self-improvement. I also agree that Des Cousens or I may terminate this relationship at any time for any reason whatever. I realise that although Des Cousens has considerable training and experience, the training and insights he provides, are not a cure, and I accept that I am paying for his time, expertise, and insights, irrespective of any particular result.