Hypnotherapy Client Intake Form

Name*

First NameLast Name

What do you prefer to be called?

Date of birth*

Date

What is your gender?*

MaleFemaleNon-binaryI prefer not to say

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone *

Area CodePhone Number

How did you hear about us?

Reason for Seeking Hypnotherapy or Regression Therapy*

What do you hope to achieve with hypnotherapy? *

Is this your first time being hypnotized and if not, how was your previous experience? *

Do you have any intense fears? (ie. heights, stairs, tunnels)*

What places/hobbies are relaxing for you?*

Is there any other information/concerns you would like me to know?

What is your learning style? (Choose one or all that apply)*

Visual (seeing, reading)Auditory (listening, talking)Kinesthetic (feeling, touching, doing)I don't know

Spiritual Beliefs or Orientation:*

Do you wear contact lenses? During hypnosis your eyes will be closed for at least 45 minutes. If your contacts will cause eye irritation, you may want to bring your lens holder and solution so you can remove them just before hypnosis.

YesNo

Are you hearing impaired? You may want to position yourself for optimal hearing. If you normally wear a hearing aid, please use it as you will have your eyes closed and will not be able to lip-read during a session.

YesNo

Have you been diagnosed with any of the following? ***

** IF YOU HAVE ANY OF THE ABOVE CONDITIONS, A MEDICAL OR MENTAL HEALTH PROVIDER'S WRITTEN REFERRAL IS REQUIRED.*

I Understand

Do you have any mental or behavioral condition requiring continued treatment by a psychiatrist or psychologist? If yes, please explain. *

Prescribed Medications (** Please also state what medication is for)

I, First Name* Last Name*, understand that hypnosis is a method for self-exploration and potential behavioral change. This may enable me to search for meaning and understanding and to direct my own personal growth and development. I understand that hypnosis is a trance state and that suggestions may adjust habits of thought, feeling, and behavior.

I further understand that all hypnosis is self-hypnosis.

Since I am in total control of the hypnotic state and session, I can stop a session at any time. I choose the entry point for my trance state and also what is discussed while in that altered state. I understand that the facilitator may use symbols and symbolic language which I will interpret according to my own belief system.

I enter into hypnosis willingly and out of my own desire for self-exploration and/or behavioral change. Furthermore, I am consenting to these sessions on my own initiative and I realize that hypnosis is not offered as a substitute for physical, emotional, or psychological diagnosis and care.

By permission, sessions may be recorded (audio only) for personal use of the participants directly involved. All information revealed during any hypnosis session is agreed to be strictly confidential.

I release Pure Transcendence Healing, LLC from any liability for claims resulting from these sessions.

My commitment to hypnosis will be for sessions payable at time services are rendered at a total cost of $120.00/hour. If mutually agreed that additional sessions would be beneficial, they can be scheduled and paid for per session.

It is agreed that 24 hours advance notice by phone must be given to cancel an appointment. For a prepaid program of sessions, any missed appointment without proper cancellation will be forfeited. If paying per session, $50 will be added to the cost of the next scheduled appointment for any non-timely cancellation.

Signature*

Today's Date*

Date

Please verify that you are human*

Hypnotherapy New Client Intake Form

Informed Consent

I further understand that all hypnosis is self-hypnosis.