Clinical Intake Form
ALL INFORMATION IS PERSONAL AND CONFIDENTIAL
Name
*
First Name
Last Name
Date:
*
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Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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?
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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?
*
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?
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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?
*
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:
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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:
*
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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*
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