New Client Intake Form

New Client Intake Form
Name:
Date:

MonthDayYear
Date
Address:
Date of Birth:

MonthDayYear
Date
Sex:
Marital Status:
Home Phone:
Work Phone:
Cell Phone:
Email:
example@example.com
Preferred Method of Contact:

Phone CallTextEmail
Employer:
Occupation:
What is your primary reason or goal for today's visit?
Below is a list of common concerns that lead people to seek professional assistance. Please check all that apply to you.

Anxiety/StressGeneral FearsSmokingInsomniaSports PerformanceChronic PainLack of MotivationAlcohol/Drug UseDepressionLow Self EsteemTest AnxietyWeight IssuesPhobic ReactionsUnwanted HabitsSurgical AnxietyRelationship IssuesGoal Setting
Relevant Medical Condition(s):
Are you currently under a physician's care for these conditions?

YesNo
Physician Name:
Physician Phone:
Date of your last visit with your physician:

MonthDayYear
Date
Note: If the reason for today's visit has to do with a medical issue, it will be necessary to obtain your physician's approval to use hypnotherapy as an adjunct to medical treatment.
Are you currently under the care of a mental health professional?

YesNo
Mental Health Physician:
Phone:
Did they refer you or are they open to hypnosis?

YesNo
Have you ever been hypnotized before?

YesNo
Do you meditate?

YesNo
Briefly describe your spiritual or religious beliefs or life philosophy:
How did you learn of our practice?
Participation Agreement: I acknowledge that in order to be successful in reaching my goals, I must accept that the following tenets are important to the process: I understand that my health and well-‐being depend on how well I care for myself physically, emotionally, intellectually and spiritually. I accept that my thoughts, feelings and desires directly determine the course of my life and my relationships. I recognize that blaming others or myself serves no purpose. I acknowledge that I am responsible for my experience of life as I make the choices and take the actions, which shape my life. I agree to be an active participant in my hypnotherapy process and see myself as an equal partner in the success of the process. I can demonstrate this by being on time for my sessions and being fully present.
Client/Co Therapist Printed Name:
Signed:

Clear
Date:

MonthDayYear
Date
My Commitment to You: I agree to use my abilities and expertise to facilitate such changes as are mutually agreed to be in your best interest. I will offer you my undivided attention during our scheduled sessions. I am professionally committed to assisting you in using your inner resources to achieve your goals in the shortest possible time. Victoria Tabb C.ht, HHP
Signature

Clear
Should be Empty: