Life-Changing Hypnosis Client Intake Form

CLIENT INTAKE FORM

PRIVATE AND CONFIDENTIAL
Client Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *

Area Code or Country Code Phone Number
Which contact number may we leave a message? *
Emergency Contact Name *
First and Last Name
Emergency Contact Phone Number *

Area Code or Country Code Phone Number
Employer/Occupation
Referred By (if any)
Hypnosis History
If you were referred by a medical professional, do we have your permission to discuss your progress with him/her? *
Has anyone ever tried to hypnotise you? If yes, please explain *
Do you believe that you were hypnotised? Why? *
If question does not apply type: N/A
Generally, how did it go for you? *
If question does not apply type: N/A
Reason why you are seeking hypnosis now? *
Any previous attempt to address this issue? *
We find it useful to sometimes use a holistic approach (mind body spirit) when appropriate. Would you consider yourself a spiritual person? *
Medical History
Are you currently undergoing medical or psychological treatment for the above issue? If yes, please include the name of the clinic and doctor. *
Have you been under a doctor's care in the past year? If yes, please include your condition and the name of the clinic and doctor. *
Have you ever been treated for emotional problems? *
Are you currently receiving treatment or counseling for emotional problems? If yes, please include the name of the clinic and doctor. *
Have you ever been treated for: Seizures / Heart / Diabetes / Epilepsy / Pain / Mental Disorder *
Please list all that apply
Are you currently taking any medications? If yes, please include the medication name. *
Reason for medication? *
If question does not apply type: N/A
Have you had any prolonged illness? If yes, please include name of illness. *
Please list seven benefits you expect to gain from making the change(s) you would like to make through the help of hypnosis.
1. *
2. *
3. *
4. *
5. *
6. *
7. *
Please check as many of the following as it applies to you. *

I often feel that I should be punished for something I once did. I know of a past experience or relationship that could be causing this problem. I am aware of an internal conflict that may be causing part (or all) of my problem.
If I get better, I stand to lose __________________________________ *
Fill in the blank
If I wasn't so much like ___________________, I'd be much happier. *
Fill in the blank
Disclaimer

Hypnotherapy complements conventional medical treatment and it does not cure or claim to cure medical conditions. For prevailing medical condition, clients are advised to consult their Physician prior to any hypnotherapy session.
Your Initials *
First letter in your first name and first letter in your last name (i.e. Jane Doe = JD)
Current Date *

Month Day Year
Date (Month/Day/Year)
Client's Signature *

Clear
Parent/Guardian Signature (Signature is required if client is under 18 years old)

Clear
Should be Empty:

CLIENT INTAKE FORM

Client Information

Hypnosis History

Medical History