New Client Medical History Form

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Welcome to Sandy Ames Hypnotherapy Clinic.

We very much look forward to working together with you toward a happier, healthier life!
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LIFE HISTORY QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions, as fully and as accurately as you can, you will provide your therapist with important information, without using your actual therapy time. The whole thing takes about ten minutes. The information in this questionnaire will be kept by your therapist and will not be disclosed to anyone without your written permission. Case records are strictly confidential. If you do not wish to answer a question, simply move onto the next question if it is not required. Enjoy your time filling it out!
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PLEASE RETURN THIS COMPLETED INTAKE AT LEAST 48 HOURS PRIOR TO FIRST SESSION.

Guess what? You only need to fill out what you want!

Most people say they enjoy the process, as it gets them thinking.

Sandy will go over your answers before your session. So, the more you provide, the more you are off and running once you start your session!
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Full Name* This field is required.
First Name
Middle Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State
Post Code
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Please Select
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
Curaçao
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
United States
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
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Birth Date* This field is required.
Day
Month
Year
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So that makes you how old? Thanks!
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E-mail* This field is required.
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Mobile Phone Number* This field is required.
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How did you hear about us?
Please Select
Please Select
Google
Referred
Facebook
Health practitioner
True Local
Internet
Voucher
Other
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If you were referred, whom can we thank for the referral?
Full name please
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Occupation
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Who presently lives with you?
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Marital Status
Single
Married
Partnered
Divorced
Separated
Widowed
It's confusing
Just started dating someone new
Just broke up
Other
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How many times have you been married?
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Emergency Contact* This field is required.
name, relationship, and phone (_ _ _) _ _ _-_ _ _
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Have you ever done Hypnotherapy before?
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Please Select
Yes
No
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State in your own words the nature of your main issues and their duration:* This field is required.
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How and when did this begin?
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On a scale of 1-10, (1 is mild, 10 is incapacitating), please estimate the severity of your issues:
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What other forms of therapy have you tried? How long? How did they work for you?
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What is your goal?* This field is required.
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Why is this important to you, and what will your life look like when achieved?* This field is required.
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What is your typical exercise routine?
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How many glasses of water do you typically consume in a day?* This field is required.
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How many cups of coffee/tea/soda do you typically consume in a day?* This field is required.
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How many alcoholic drinks per week? Is this a concern?
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Do you smoke? How much? Do you want to quit?
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What is your meditation and/or relaxation routine?
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What time do you usually fall asleep? Wake up?
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What do you typically do before bed?
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Is falling asleep or staying asleep an issue for you?
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Do you wake up feeling rested?
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What time do you usually eat dinner?
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What nutritional supplements are you taking?
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What medications are you taking?
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Any other drugs or lifestyle choices I should know about?
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What sort of work are you doing now?
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What sort of work have you done in the past?
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Does your present work satisfy you? (If not, in what ways are you dissatisfied?)
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Ambitions: Past and Present:
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Any other drugs or lifestyle choices I should know about?
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Present interest, hobbies and activities:
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How is most of your free time occupied?
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What is the last grade of school you completed?
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Scholastic abilities; strengths and weaknesses:
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Were you ever bullied, severely bullied or severely teased?
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Do you make friends easily? If so, do you keep them?
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List five main fears:
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Check all that apply to you:
headaches
financial problems
fainting
palpitations
dizziness
no appetite
bowel disturbances
stomach trouble
insomnia
nightmares
fatigue
alcoholism
feel tense
take sedatives
tremors
unable to relax
suicidal ideas
shy with people
depressed
feel panicky
take drugs
don't like weekends
sexual problems
can't make decisions
don't like vacations
can't make friends
over rambunctious
can't keep a job
disoriented
unable to have a good time
concentration difficulties
memory problems
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In what areas of the family is there compatibility?
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In what areas is there incompatibility?
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How do you get along with your in-laws? (this includes brothers/sisters in-law)
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How many children do you have? Please list their sex and age.
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Do any of your children present special needs?
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Give details of any previous marriage(s).
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Father: Living or deceased? If deceased, your age at the time of his death? If alive, father's present age? Occupation? Health?
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Mother: Living or deceased? If deceased, your age at the time of her death? If alive, mother's present age? Occupation? Health?
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As a child in what ways were you punished by your parents?
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Give an impression of your home atmosphere (i.e., the home in which you grew up). Mention state of compatibility between parents and between parents and children.
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Were you able to confide in your parents?
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If you have a step-parent, what was your age when your parent remarried?
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Give a description of your religious training.
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If you were not brought up by your parents, who brought you up, and between what years?
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Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.?
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Who are the most important people in your life?
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I am
I am
I am
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I feel
I feel
I feel
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I think
I think
I think
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I wish
I wish
I wish
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Check all that apply to you:
I would like to : Get advice on how to deal with my life and with other people.
I would like to : Have my therapist respond to me on a person-to-person basis.
I would like to : Get better self-control.
I would like to : Get clarity regarding which things I think and feel are real and which things are mostly in my mind.
I would like to : Work out a particular issue that's been bothering me.
I would like to : Get my therapist to say what he/she really thinks.
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Last Chance: What else should we know about you?
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Please sign below that you have received and understand our policy:* This field is required. SANDY AMES HYPNOTHERAPY ACKNOWLEDGEMENT OF SERVICES AND FEES SELF-IMPROVEMENT PROGRAM I, the undersigned, acknowledge that I understand: The program of conditioning will include an undetermined number of private sessions, depending on my individual needs. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (CA Business and Professions Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of my sessions. I agree to pay Sandy Ames Hypnotherapy, c/o Jamie Lee Enterprises LLC, in full, before the date of each session. Paid sessions expire after one year. I agree to give you 24 hours notice for all cancellations or changes of scheduled appointments. I understand that missing a scheduled appointment without prior cancellation, or canceling with less than 24 hours notice, may be charged to me at the current full rate.
Clear
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SAH Intake Session - $495.00* This field is required.****Due to high demand and limited availability, payment for intake session is required in order to hold your sacred and exclusive session time. Please select your payment method.****
Paypal
Stripe
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How will we be meeting?* This field is required.People often ask how effective video calls are for hypnotherapy. We promise, it's the same! Our office IS open, if in-person is still your preferred choice at this time. Please choose one option. We can always change this later.
Zoom (Here's the Link:) https://us02web.zoom.us/j/5653647889?pwd=c2NhSWl4RFVvR2E5R0pDZkQ0dXVYdz09
In-office (with Covid safety precautions)
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When's good?Open M-F 8am-9pm In-person or Zoom (Weekends available by special request) Many time slots are already booked. Please give us some dates/times that work best for you. We'll confirm back ASAP!
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Favorite way to pay* This field is required.How will you be paying? (You can change this any time)
Credit Card
Venmo
Zelle
Google Pay
PayPal
Cash
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CARD ON FILE:
(If credit card is your preferred method of payment, please feel free to fill this out. We will charge you after your first session. If you have chosen a different payment method, just skip this, hit SUBMIT, and you're all set.)

Name on Card:
Credit Card #:
Expiration:
CVV (3 digits, or 4 for AMEX):
Zip Code
Please keep my card securely on file, thanks.
Signature

Now, just hit SUBMIT, and you're all set!

If you've filled this out in PDF form, you can email this back to SandyAmesHypnotherapy@gmail.com

website: SandyAmesHypotherapy.com
phone: 917-426-6322
@Sandy.Ames.Hypnotherapy
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