Hypnotherapy Intake Form

Hypnotherapy Intake Form
Today's Date *

Month Day Year
Date
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Preferred Pronouns
he/she/they/etc.
Occupation & or Significant Hobbies
Phone Number *

Area Code Phone Number
Email *
example@example.com
Emergency contact name *
Emergency contact phone # *
Any other contact notes
Health History
Chronic (ongoing/stable) Condition:

None Spinal Injury or Fixation Cardiac Hearing Impaired Respiratory Chronic Depression Diabetic Anxiety Epilepsy Chronic Pain
(Chronic) If yes to any option above, please explain
Acute (recent/short term) Condition:

None Recent Injury Recent Onset Depression Recent Surgery (less than 2 months) Recent Suicidal Thoughts New/Recent Pain or Discomfort Active Infection
(Acute) If yes to any option above, please explain
How would you rate your pain level today? *
1-10, and explain if general or specific locations, etc.
Are you actively under a physicians care? *

Yes No
If Yes, Please explain (include Physician contact information if appropriate)
Are you taking any medication(s)? *

Yes No
If Yes, Please list current medications.
You can include non-prescription meds, herbs, etc., if you feel they are pertinent
Do you smoke? *

Never Socially/Occasionally Yes-less than 1 pack/day Yes-more than 1pack/day
Do you drink? *

Never Rarely/Occasionally Regularly Heavily
How would you rate your stress level (on average, or today)? *
High/Med/Low-explain
What would you like to focus on today, or in general? *
prompts: If you could heal one thing today, what would it be? or What brings you here today?
What, if anything, have you tried to work on this issue? *
possibly: medication, therapy, physical therapy, yoga, 'western' medicine, or various integrative modalities
Have you ever experienced/ practiced... (pick any or all modalities that apply) *

Hypnotherapy (not stage hypnosis) Self-hypnosis/Guided Visualizations (CD or download, for instance) Meditation Tapping (EFT) Reiki Treatment Polarity Therapy Treatment Craniosacral Unwinding Personal or Life Coaching NLP (Neurolinguistic Programming) None
Are you a trauma survivor? If yes, please describe briefly (and only as much as you are comfortable...if you'd prefer to talk in person, or not disclose the precise nature of the trauma at this time, know that we respect you and your boundaries)
Favorite or personally powerful images/places/concepts, etc. (pick all that apply) *

Forest/Trees Beach Water (oceans, rivers, waterfalls) Desert Stars/Space Colors or light Technology (computers, screens, etc.) Books, Libraries Spiritual (but not necessarily religious) images/concepts (Universe, energy beings, angels, fairies, totem animals, chakras/energy centers, ancestors, etc.) Religious images/concepts (God, gods/goddesses, Angels, church, temple, etc.) Not sure/Doesn't matter
Any fears or phobias (or other triggers) we should be aware of? *
Include any imagery or concepts that might trigger anxiety or discomfort
Is there anything that would make it difficult for you to relax?
Do you believe yourself to be mostly (also called learning style or communication style)(pick any or all that apply) *

Visual ("I see") Auditory ("I hear") Kinesthetic/Somatic ("I feel," "I taste," or "I smell") Audiodigital ("I know" or "I understand") I don't know which one describes me (or don't care)
Do you believe yourself to be mostly (pick the one that best describes you) *

Introverted (prefers solo time, or needs a lot of alone time to recharge) Extroverted (prefers time with others, gains energy from time with others) Ambiverted (needs a balance of alone time and time with others) I don't know (or don't care)
(I) Using single words or short phrases, list what you believe to be most important/valuable to you. *
concepts like honesty, spirituality, independence, connection, safety, etc.
(+U) Using single words or short phrases, list 3-5 things you like best about yourself. *
(-U) Using single words or short phrases, list 2-3 things you'd like to improve (or actively dislike) about yourself. *
Do you have any questions regarding hypnotherapy or guided imagery?
Is there anything else you'd like to share?
any concerns or things you would like us to know before we begin, in order to create the best experience for you
Hypnotherapy Consent:
I consent and request to be guided through any combination of relaxation, guided imagery/visualization, hypnosis, stress reduction, and mindfulness techniques. I have been informed of the nature, safety, and usefulness of hypnosis. I understand that personal results will vary and there are no expressed or implied guarantees of specific results . I am also aware this is non-medical in nature and will consult my health care provider for any medication changes.
Indicate consent: *

I DO consent to receiving hypnotherapy/guided imagery I DO NOT consent to receiving hypnotherapy/guided imager
Signature *

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Hypnotherapy Intake Form

Health History