INTROSPECTIVE HYPNOSIS INTAKE FORM

INTROSPECTIVE HYPNOSIS INTAKE FORM
Introspective Hypnosis

is a method that combines Ericksonian hypnosis techniques, enhanced by spirituality and the dynamics of forgiveness, in order to achieve behavioral changes. We can receive and resolve psychosomatic answers that contribute to the relief for the patient. This therapy can be used to treat various behaviors, such as phobias, fears, angst, sadness,anxiety, anorexia, bulimia, low self-esteem, insecurities, complexes, migraines, obesity, obsessive compulsive disorders, allergies and/or addictions.
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Personal Information
Name*

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Birth Date*

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Occupation (what you do the majority of your time?).*
Family Questions
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Health Questions
Health Issues? Please write N/A if not Applicable.*
Are you currently taking any medicine?*

YesNo
If yes, please list Medication and for what reason.
Have you received any psychological treatment during the past year? If yes, please tell me about it.*

Have you every been treated for any of the following?*

	Yes	No
Abortions?
Have you any Organs transplanted?
Have you ever been hypnotized?
Major Accidents?
None Of the above

Other
Favorite Landscape. Most relaxing place for you to be, either imagined or not. Please describe:*
Please identify three emotions that you feel as it relates to the reason why you are having this regression, 1. representing the most intense. If there aren't three just indicate ones you can. i.e:. 1)Sadness 2)Anger 3) etc...
Spiritual Belief System? *
Can you name some important events is your life?*
What is your expected outcome of this Introspective Hypnosis Session?*
By signing the form below, I Your Name Here* confirm that the information given in this form is true, complete and accurate. I agree and acknowledge that counseling and/or hypnosis treatment does not supersede or replace any medical treatments and that all the outcomes of the session are totally the my responsibility.
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Introspective Hypnosis