Clinical Intake Form
ALL INFORMATION IS PERSONAL AND CONFIDENTIAL
Name
*
First Name
Last Name
Date:
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Month
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Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number(s)
*
Email:
*
example@example.com
Birthdate:
*
/
Month
/
Day
Year
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?
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What do you want to accomplish with hypnosis?
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Anxiety and Stress
Bad Habits/Smoking Cessation
Business and Finance
Child and Adolescent Issues
Childbirth
Confidence and Personal Development
Fears or Phobias
Grief or Coping With Loss
Meditation and Spiritual Energy
Optimal Weight and Control
Pain, Medical and Dental
Past Life Regression
Relationships
Relaxation
Sports Performance
Test Taking, Memory, Academic Performance
What is your prior experience with hypnosis?
*
None
Have been hypnotized at a stage show
Have been hypnotized one on one
Have listened to hypnosis recordings
Have read books on hypnosis
Have friends or family who have been hypnotized
What are your beliefs about hypnosis?
*
It changed my life
I think it can help me
I will try it and see what happens
I am a skeptic
Please explain your reasons for seeking hypnotherapy:
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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?
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What are you willing to do to reach your outcome? What have you done up until this point so far?
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How do you benefit by continuing in your current status?
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Anything else you would like to share about this issue?
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Current life stresses:
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What do you do to handle tension and stress? Do you meditate?
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On a scale of 1-10, what is your stress level?
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Do you drink alcohol?
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Never
Once a month
Once a week
A few times a week
Daily
Binge drinking
Received clinical treatment
Recovering alcoholic
Do you smoke cigarettes, vape, or use chewing tobacco?
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Never have
Former user
Light user
Heavy user
How much do you use per day?
If you quit, how long ago?
What age when you started smoking/vaping/chewing?
Do you use marijuana?
*
No
Yes
If so, how often?
Do you use vape cartridges?
Would you like to cut back or quit?
Do you use other drugs?
*
No
Frequently
Occasionally
Received clinical treatment
Recovering addict
Do you use other drugs continued
Cocaine or other stimulants
MDMA or other club drugs
Heroin or Methadone
Unprescribed pain pills
Prescription pain pills
Unprescribed anxiety medication
Prescription anxiety medication
Other drugs:
Do you have sleep difficulties?
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Rarely
I don’t get enough sleep
I have trouble falling asleep
I have trouble staying asleep
I sleep too much
Eating patterns:
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Are you on a special diet?
I eat mostly healthy foods
I don’t eat regularly
I overeat
I do not eat enough
I binge eat
I purge myself when full
I snack too often
Late night eating
Food allergies
Exercise patterns:
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I work out frequently
I exercise occasionally
I do not get enough exercise
I have a health condition that limits my ability to exercise
How much do you weigh, and what is your target weight?
*
In my personal relationships I am:
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Unsatisfied
Sometimes satisfied
Mostly satisfied
I 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:
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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?
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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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Month
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Day
Year
Date
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