New Client Information
Thank you for taking a few moments to complete this form. The information you're providing will help me help you achieve your goals. (Five pages. Average time for completion: 15 minutes.)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Peak Performance Hypnosis?
Google search
Social media (Facebook, Instagram, etc.)
Media appearance
Referral
If you came here through a referral, who can I thank for referring you?
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Occupation (former occupation, if retired)
Date of birth
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Month
-
Day
Year
Date
Age
Marital status
Single
Married/Partnered
Widow/wiodower
Other
Spouse/Partner's name
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Health Information
Finish this sentence: Overall, my health is...
Excellent
Good
Fair
Poor
Number of months since last physical exam:
Doctor's name and phone number
Are you currently being treated by a healthcare or mental health professional? If so, for what?
Please list any medications or supplements you're currently taking, and what they're for:
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Goals & Outcomes
Breifly describe the goal or outcome you want to work on:
Why is this a problem for you? What problems is it causing in your life now?
How will things get worse unless you start making changes now?
What would you be willing to let go of or give up to handle this concern, problem or situation?
What would you not be willing to let go of or give up?
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Have you been hypnotized before? If so, under what conditions or for what purpose?
Have you ever seen someone be hypnotized? How did you feel about that?
I understand that if I want things to change, I have to be willing to change things. And I am willing to change things.
Yes
No
I accept responsibility for myself, my choices, and my actions.
Yes
No
I agree to participate wholeheartedly in the work I am undertaking.
Yes
No
I understand that Jeffrey Richards is a hypnotist and not a medical doctor or licensed mental health professional, and that the services he provides are not a substitute for professional physical and/or mental health services, nor are they intended to diagnose or treat any recognized medical or mental health condition.
Yes
No
I hereby attest that information I have provided is true and complete to the best of my knowledge.
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