QuinSentia Therapist & Behavior Engineer Intake Questionnaire

For Organizations & Professional Practices.QuinSentia works with licensed and qualified professionals to provide structured behavioural mapping and modification support. This intake helps us understand your credentials, scope, availability, and alignment with our standards of practice.

FORM INSTRUCTIONS

Please complete this form accurately and completely.
This questionnaire is used to evaluate organizational fit, ethical alignment,
and readiness to collaborate within QuinSentia’s behavioural-engineering framework.

QuinSentia is not an emergency or crisis service.

Identity & Contact Information

Full Legal Name

Preferred Professional Name

Email Address

Phone Number

Preferred Contact Method

Email Phone Platform Messaging

Country of Residence

City

Time Zone

Primary Practice Type

Other

Professional Classification

Others

LICENSURE, CREDENTIALS & EDUCATION

Highest Level of Education

Doctorate Master’s Bachelor’s Other

Field(s) of Study

Institution(s)

Licensure(s) Held

License Type

License Number

Issuing Authority

Jurisdiction(s) Covered

Active / Inactive

Are you currently in good standing with all licensing bodies?

Yes No

Have you ever been subject to disciplinary action?

Yes No

Scope of Practice & Modalities

Others

Populations You Do NOT Work With

Are you comfortable working within a non-diagnostic, behavioural-engineering framework?

Yes No With clarification

Availability & Engagement Preferences

Session Format

Virtual In-person Hybrid

Typical Weekly Availability (hours)

5–10 10–20 20–30 30+

Preferred Session Length

30 min 45 min 60 min

Are you open to short-term structured protocols (4–8 weeks)?

Yes No Case-by-case

ETHICS, SAFETY & BOUNDARIES

How do you determine when a client is outside your scope?

What is your approach to referral or escalation when needed?

How do you handle informed consent and client autonomy?

What does ethical practice mean to you in one or two sentences?

Professional Character & Alignment

When a client is resistant, you tend to:

Which best describes your style?

Structured & systems-based Intuitive & relational Evidence-driven Hybrid

How do you respond to feedback or protocol updates?

What drew you to QuinSentia’s model?

What do you believe is most important for sustainable behavioural change?

PLATFORM & COLLABORATION

Are you comfortable documenting session summaries within a secure platform?

Yes No

Are you open to outcomes tracking and structured follow-ups?

Yes No With Clarification

Do you collaborate well within multidisciplinary teams?

Yes No With Clarification

Final Confirmations

I confirm that the information provided is accurate I agree to QuinSentia’s standards of conduct and scope I understand QuinSentia is not an emergency or crisis service

Date

Digital Signature

QuinSentia is a global behavioral engineering clinic and network that helps individuals transform subconscious patterns, connects licensed professionals with the right clients, and empowers organizations to optimize human performance, resilience, and culture.

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QuinSentia Therapist & Behavior Engineer Intake Questionnaire

FORM INSTRUCTIONS

Identity & Contact Information

Professional Classification

LICENSURE, CREDENTIALS & EDUCATION

Licensure(s) Held

Scope of Practice & Modalities

Availability & Engagement Preferences

ETHICS, SAFETY & BOUNDARIES

Professional Character & Alignment

PLATFORM & COLLABORATION

Final Confirmations

Quick Links

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Confidential. Non-emergency service. If you’re in crisis, call local emergency services.