Client Intake Form

Hello Beautiful $FIRSTNAME$,

I’m looking forward to working with you. To help me prepare and support you in the best way possible, please take a few minutes to complete the form below.

If a question doesn’t apply, you can simply write “N/A.”

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Full name, phone, and email

Date of Birth, Marital Status, Number of Children & Employer

How did you hear about me? Have you ever been hypnotized? If so, why, and was it a positive experience?

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MEDICAL & EMOTIONAL HISTORY

Have you been under a doctor’s care within the past year? Yes ___ No ___
If yes, please explain:

Have you ever been treated for an emotional or mental health concern? Yes ___ No ___

If yes, are you currently receiving treatment or counseling? Yes ___ No ___
If yes, please explain:

Please list any past or present prolonged illnesses (with approximate dates):

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For Your Safety and Comfort During Our Session, Please, Answer

Have you ever been treated for any of the following:
Heart Conditions ___ Diabetes ___ Epilepsy ___ Panic Attacks ___

Are you currently taking any medications? Yes ___ No ___
If yes, please list medications and reasons:

Are you currently receiving treatment for any medical or psychological condition?
If yes, please explain:'Are you currently receiving treatment for any medical or psychological condition? If yes, please explain:

GOALS FOR HYPNOSIS

What is the main reason you are seeking hypnosis?
Have you made previous attempts to resolve this issue?
If yes, what were the results?

Any additional information you'd like me to know

* are required fields