Clinical Intake Form

Clinical Intake Form

ALL INFORMATION IS PERSONAL AND CONFIDENTIAL
Name*

First NameLast Name
Date:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number(s)*
Email:*
example@example.com
Birthdate:*

MonthDayYear
Date
Gender:*
Emergency Contact, Relationship, Telephone Number(s)*
Occupation and Employer/School:*
Religion or Spiritual Preference:*
Favorite Relaxing Places (beach, forest, etc)*
Favorite Color:*
What do you do for fun, any hobbies?*
What are your three biggest personal strengths?*
Anxiety and StressBad Habits/Smoking CessationBusiness and FinanceChild and Adolescent IssuesChildbirthConfidence and Personal DevelopmentFears or PhobiasGrief or Coping With LossMeditation and Spiritual EnergyOptimal Weight and ControlPain, Medical and DentalPast Life RegressionRelationshipsRelaxationSports PerformanceTest Taking, Memory, Academic Performance
NoneHave been hypnotized at a stage showHave been hypnotized one on oneHave listened to hypnosis recordingsHave read books on hypnosisHave friends or family who have been hypnotized
It changed my lifeI think it can help meI will try it and see what happensI am a skeptic
Please explain your reasons for seeking hypnotherapy:*
What objectives are you seeking to achieve?*
What stops you from having what you want now?*
What will this outcome do for you? How will it affect your life? How will you feel if you don't reach your outcome?*
What are you willing to do to reach your outcome? What have you done up until this point so far?*
How do you benefit by continuing in your current status?*
Anything else you would like to share about this issue?*
Current life stresses:*
What do you do to handle tension and stress? Do you meditate?*
On a scale of 1-10, what is your stress level?*
NeverOnce a monthOnce a weekA few times a weekDailyBinge drinkingReceived clinical treatmentRecovering alcoholic
Never haveFormer userLight userHeavy userHow much do you use per day?If you quit, how long ago?What age when you started smoking/vaping/chewing?
NoYesIf so, how often?Do you use vape cartridges?Would you like to cut back or quit?
NoFrequentlyOccasionallyReceived clinical treatmentRecovering addict
Cocaine or other stimulantsMDMA or other club drugsHeroin or MethadoneUnprescribed pain pillsPrescription pain pillsUnprescribed anxiety medicationPrescription anxiety medicationOther drugs:
RarelyI don’t get enough sleepI have trouble falling asleepI have trouble staying asleepI sleep too much
Are you on a special diet?I eat mostly healthy foodsI don’t eat regularlyI overeatI do not eat enoughI binge eatI purge myself when fullI snack too oftenLate night eatingFood allergies
I work out frequentlyI exercise occasionallyI do not get enough exerciseI have a health condition that limits my ability to exercise
How much do you weigh, and what is your target weight?*
UnsatisfiedSometimes satisfiedMostly satisfiedI am very happy with my relationships with others
Did you experience childhood trauma? Please enter your ACES Adverse Childhood Events Score (link available on website).*
Have you experienced emotional, physical, or sexual abuse?*
Have you had other traumatic experiences in your life?*
Are you currently having any suicidal thoughts or intention to physically hurt someone?*
List all medical and mental health conditions for which you have been diagnosed or for that you are receiving treatment:*
Current prescription medications and supplements:*
What is your pain level on a scale of 0 10? Where is it located and what does it feel like?*
Is there anything health or body related you would like to address?*
Any other health concerns, fears, or upcoming surgeries/procedures?*
Is there a physician or other practitioner that you would like me to speak with?*
All information on this form is true and correct to the best of my knowledge:
Signature:*

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Date:*

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