Initial Interview Form

JackieBASTONI
HYPNOSIS
Clinical Interview Intake Form
Date

Month Day Year
Date
Time
Name
FIRST
MIDDLE
LAST
Address
Preferred Contact Phone Number: (
Email
example@example.com
Dat Of Birth
What goals do you want to accomplish with hypnosis today:
Stress Management
Smoking Cessation
Weight Loss
Overcome Fears Specify
Test Taking
medical Condition Specify
Pain Management
Sexual Difficulties
Other Specify
What is your prior experience with hypnosis:
None
Have been hypnotized in a stage show
Have been hypnotized in a stage show

Have been hypnotized one on one
Have listened to hypnosis audio(s)
Have read books on hypnosis
Have friends/family who have been hypnotized
What are your beliefs about hypnosis?

I think it can help me I will try it and see what happens I am a skeptic
What are your three biggest personal strengths?
1.
HEALTH: List all medical and mental health conditions for which you are currently being treated.
Diagnosis
Treating physician
Medications
Diagnosis
Treating physician
Medications
Diagnosis
Treating physician
Medications
List any other health concerns, fears or issues
List any other medications
How much do you currently weigh?
What is your target weight?
Do you drink alcohol?

Never Once a month
Once a week
A few times a week
Daily
Do you smoke cigarettes?

Never have Former smoker - If so, when did you quit?:
Former smoker - If so, when did you quit?:
Yes, I am a light smoker If so, how many cigarettes per day?
Yes, I am a light smoker - If so, how many cigarettes per day?

Yes, I am a heavy smoker - If so, how many cigarettes per day?
Your age when you started smoking?
NO
YES
If so, How often?
frequently
occasionally use other drugs?
Cocaine or other stimulants
Extacy or club drugs
Heroin or Methadone
Unprescribed pain pills
Prescription pain pills
Prescription anti anxiety medications (such as Valium or Xanax)
Unprescribed anti anxiety medications
Other drugs Specify
Do you have sleep difficulties?

Rarely
I don't get enough sleep
I have trouble falling asleep
I have trouble falling asleep

I have trouble staying asleep I sleep too much
I am on a special diet Specify
I am on a special diet - Specify

Ieat mostly healthy foods I don't eat regularly I overeat
I do not eat enough
I binge eat
I binge eat

I purge myself when full I snack too often
work out frequently Specify
I work out frequently - Specify:
exercise occasionally Specify
I exercise occasionally - Specify

I do not get enough exercise I have a health condition that limits my ability to exercise - Specify
In my personal relationships, I am:
Unsatisfied
Sometimes satisfied
Sometimes satisfied

Mostly satisfied I am very happy with my relationships with others
What do you do to handle tension and stress?
What do you do for fun?
What are your hobbies?
What do you want to accomplish with hypnosis?
Other information you would like to share
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

JackieBASTONI

HYPNOSIS

FIRST

MIDDLE

LAST