Clinical Intake Form

Clinical Intake Form

ALL INFORMATION IS PERSONAL AND CONFIDENTIAL
Name *

First Name Last Name
Date: *

Month 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? *
What do you want to accomplish with hypnosis? *

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: *
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? *
Do you drink alcohol? *

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? *

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? *

Rarely I don’t get enough sleep I have trouble falling asleep I have trouble staying asleep I sleep too much
Eating patterns: *

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: *

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: *

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: *
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: *

Month Day Year
Date
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