Client Induction Form
Allow yourself some time and space to carefully fill out your answers. Reflect on each question with as much detail as you can to help accelerate and deepen the changes you want to make. You may also save your answers and come back at any time before submitting your form. All your data is secure, encrypted and in compliance with GDPR.
Name
*
First Name
Last Name
Date of birth
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Country Code
Phone Number
Emergency Contact Name
*
First Name
Last Name
Relationship To You
*
Emergency Contact Number
*
-
Country Code
Phone Number
Family Doctor/GP/Medical Practice Contact Details
*
Do you consent to me contacting your Family Doctor/GP if necessary? (This may only be needed in special circumstances)
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Yes
No
Are you currently on any medication? Please give details:
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Do you have epilepsy? (epilepsy can be triggered by hypnotic trance) If yes, please give further details:
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The following conditions are contraindicated for hypnotherapy: Bipolar Disorder, Borderline Personality Disorder, Psychosis, Psychotic Episodes, Schizophrenia. Have you ever been diagnosed with any of the above listed conditions?
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No
Yes (please give further details below)
Details:
Alcohol Units Per Week
*
Do you smoke/vape? How many times a day?
*
Do you take recreational drugs? Please give details:
*
What are your current average stress levels?
*
Not at all stressed
1
2
3
4
Very stressed
5
1 is Not at all stressed, 5 is Very stressed
What are your current average anxiety levels?
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Not at all anxious
1
2
3
4
Very anxious
5
1 is Not at all anxious, 5 is Very anxious
Please provide clear and detailed responses to the questions below. Try to answer as many questions as you can. Full answers are essential to make the best of your consultation session.
Describe in detail the problem you are having (give details about the context, emotional & physical impact, frequency, severity):
When did it first start? How often does it cause you a problem?
When did you last experience your problem? What happened? How did you feel? How did it affect you afterwards?
How does it affect your life in general? What impact does it have on your day-to-day life?
Describe any problems you may be experiencing in other areas of your life:
What are you most afraid of when it comes to performance (for example, letting yourself down, making a fool of yourself)?
Explain anything in your background or other life experiences which you believe could be linked to the problem you have now:
How was your life growing up? Describe any significant traumas or events which you may have experienced as a child:
How were your relationships with your parents or guardians when you were younger? How does that relationship impact your current life (even if they are no longer around)?
How have you tried to resolve your issue on your own? What has helped? What hasn’t helped? What has prompted you to seek help now?
What previous experiences have you had with a hypnotherapist or other practitioner around this or any other issue?
How would your life be different without your problem? What would you be doing? What would become possible? How would you feel?
What else would you like to mention which you think would be relevant and useful for your sessions?
Signature
*
I declare that the information I have disclosed provides a detailed and accurate picture of my current issues and general mental health.
Thank you for completing this induction form.
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