Pre-Assessment & Medical History Form

  • Please complete ALL sections of this form - information provided will be treated sensitively and confidentially.

  • Date of Birth*
     / /
  • Do you have a medical condition or disability?*
  • Have you had therapy or counselling before?*
  • Have you been treated for any of the following?
  • Have you had hypnotherapy before?*
  • If yes, what date/year did you do it?
     / /
  • Have you made previous efforts to solve the problem*
  • Are any of the following issues currently a problem for you? If so, please select all that are relevant.*
  • How intense are the symptoms*
  • How frequently do you experience the problem?*
  • Do you ever experience thoughts of harming yourself or ending your life?*
  • Do you have a history of suicide or mental illness in your family?*
  • Mother
  • Father
  • Parents
  • Siblings
  • Date*
     - -
  • Should be Empty: