Intake Form - Personalized POTS and MCAS Programs| NewLeafNeuro Site

New Leaf Neuro Custom Program Intake Form

Thank you for choosing New Leaf Neuro. This form will help us tailor your program to your specific needs, symptoms, and preferences. Please complete the following form with as much information as possible.

Personal Information:

First name

Last name

Email

Age

Overview:

Have you ever been diagnosed with MCAS?

Yes

No

Suspected

If yes, when were you diagnosed?

Have you ever been diagnosed with POTS?

Yes

No

Suspected

If yes, when were you diagnosed?

What are your most common symptoms? (Check all that apply):

Skin-related (e.g., flushing, hives, itching)

Gastrointestinal (e.g., nausea, bloating, diarrhea)

Respiratory (e.g., wheezing, difficulty breathing)

Cardiovascular (e.g., dizziness, rapid heart rate, chest pain)

Neurological (e.g., brain fog, headaches)

Other Symptoms

Please list any food sensitivities

How would you describe your stress level regarding your symptoms?

Low

Moderate

High

Overwhelming

What aspects of your daily life are most challenging due to your symptoms?

What are you currently doing to manage your symptoms? (write as much detail as possible).

Have you developed any phobias or fears that you did not have before? (e.g., fear of driving, fear of being alone).

Yes

Not that I am aware

Please list any phobias or fears

Guided imagery is a vital part of our recovery program. Please share what images, sounds, or places bring you comfort (e.g., nature scenes, specific locations, calming sounds), and let us know what you’d prefer to avoid, including any phobias or fears. The more details you provide, the more personalized and effective your guided imagery experience will be.

Personalizing your program:

Please share your top priorities so we can customize the program for you (e.g., better sleep, enjoying your favorite foods, regular exercise, reducing anxiety).

Other Environments

Other Activities

Do you have a favorite color, object or place that feels calming - your sanctuary? Please provide as much detail as possible.

Are there any areas in the world that you like to visit or want to visit?

Please let us know what to avoid for your guided imagery that may trigger anxiety (e.g., deep water, swimming, flying). - Please provide as much detail as possible.

Are there any specific words, phrases, or themes you find soothing and would like included in your sessions?

Are there any words, imagery, or topics you would prefer to avoid (e.g., rodents, floating) due to phobia or discomfort?

How do you typically relax? (e.g., reading, walking, listening to music)

Please add any details that might help us develop a program to best address your needs.

Consent and Agreement:

I understand that this program, including the incorporated clinical hypnosis, is a complementary approach and is not a substitute for medical treatment. I consent to participate in this program, including clinical hypnosis sessions, and I understand that results may vary based on individual circumstances.

Signature:

Date picker

Welcome To Your Custom Program, Let's Get Started!

New Leaf Neuro Custom Program Intake Form

Personal Information:

Overview:

Personalizing your program:

Consent and Agreement:

Please Submit Intake Form First & Then Go To Pay Now.