Hypnotherapy Intake Form

Hypnotherapy Intake Form
Today's Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of Birth*

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

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

NoneSpinal Injury or FixationCardiacHearing ImpairedRespiratoryChronic DepressionDiabeticAnxietyEpilepsyChronic PainOther
(Chronic) If yes to any option above, please explain
Acute (recent/short term) Condition:

NoneRecent InjuryRecent Onset DepressionRecent Surgery (less than 2 months)Recent Suicidal ThoughtsNew/Recent Pain or DiscomfortActive InfectionOther
(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?*

YesNo
If Yes, Please explain (include Physician contact information if appropriate)
Are you taking any medication(s)?*

YesNo
If Yes, Please list current medications.
You can include non-prescription meds, herbs, etc., if you feel they are pertinent
Do you smoke?*

NeverSocially/OccasionallyYes-less than 1 pack/dayYes-more than 1pack/day
Do you drink?*

NeverRarely/OccasionallyRegularlyHeavily
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)MeditationTapping (EFT)Reiki TreatmentPolarity Therapy TreatmentCraniosacral UnwindingPersonal or Life CoachingNLP (Neurolinguistic Programming)NoneOther
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/TreesBeachWater (oceans, rivers, waterfalls)DesertStars/SpaceColors or lightTechnology (computers, screens, etc.)Books, LibrariesSpiritual (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 matterOther
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 imageryI DO NOT consent to receiving hypnotherapy/guided imager
Signature*

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Hypnotherapy Intake Form

Health History