IEMT Hypnotherapy Questionnaire

IEMT Client Questionnaire

This questionnaire will help me understand areas that IEMT will be most useful and any contraindications to our sessions.

Please answer the questions as accurately as you can.

Name

D.O.B

Address: Email: Mobile

Email

example@example.com

Address

Preferred method of communication:

GP/Physician Details

Occupation

Married/Single/Divorced/In a Relationship

Does anybody else share your home

Any other relevant information

All personal data is for the Practitioners use only. If I need to contact your GP/Consultant it will be with your written consent.

Medical History: (Y/N) Epilepsy

High Blood Pressure

Low Blood Pressure

Postpartum depression

Hormonal disorders

Thrombosis

Embolism

Cancer

Stroke

Pregnant

Ever suffered a head injury that resulted in loss of consciousness or brain trauma:

Have you received in-patient psychiatric treatment:

If so: what, where and for how long

Any current medication?(please list)

Do you drink alcohol/how many units per day or week approx

Do you smoke/how many per day

If Yes what and how much

Do you take recreational drugs

If Yes what and how much

Do you take any legal highs

Caffeine intake (approx how many cups of tea/coffee per day):

Allergies

Digestive problems

Respiratory disorders

Skeletal disorders

Muscular problems

Heart problems: Aneurysm

Migraines: Psychological illness

Any Head injuries

Balance issues

Details on any of the above or any other medical issue that you feel is relevant:

Visual Problems

Please answer the questions below to help me identify where IEMT can be the most productive.

(Give as much detail as possible)

1. What's the problem

2. What do you want to change

3. How much to you want to change it: 0 = not at all 10 =completely:

4. What makes the problem worse

5. If you can compare it with something - what is this problem like:

6. If you didn't have this problem how would your life be different

7. How will you know when you have achieved your desired change

8 Have you ever experienced any change therapy before? If so what type and what were the outcomes

9. What is your understanding or expectation of the session:

10. What will you gain and/or lose when you achieve your desired change:

11. How will this change affect your family/friends:

12. Is there anything else about your situation that would be helpful for me to know:

13. What is your favorite pastime/hobby:

14. What is your best accomplishment to date:

Signature

Lori Donnelly Hypnotherapy
Wolf Creek Wellness 424-644-9598
DISCLOSURE OF SERVICES

In recognition that millions of Californians receive a substantial volume of healthcare services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials. The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code.
The purpose of a program of hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state.
A hypnotherapist is not a licensed physician or psychologist and hypnotherapy services are not licensed by the State of California. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures.
Hypnotherapists who assist clients with weight loss and/or other health and fitness goals may provide general nutritional advice and/or recommend published books, food guides and health and fitness publications. This is not a substitute for medical advice and you are advised to seek your Doctor’s approval before making any medical/health/ lifestyle changes.
Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives.
Services consist of a program of conditioning, including an undetermined number of private sessions, depending on the client’s individual needs. The hypnotist will to the best of his or her ability endeavor to accomplish the objectives of the client’s sessions. While hypnosis may be an effective technique for many purposes, the effectiveness may vary from individual to individual, and no specific results or progress can be promised or guaranteed.
The feelings and experiences one has in the hypnotic state can vary from individual to individual. Many people remain completely aware of everything that is going on while in hypnosis. Some individuals experience a hyper- awareness where sensations are perceived enriched and vivid. The ability to visualize or imagine is often enhanced. A feeling of deep relaxation is common and some people describe the hypnotic state as an escape from physical tension and emotional stress, while remaining completely alert.
The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client.
While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy.
I have received a copy of this disclosure and understand the information described above. I have also read the accompanying document which is a biography of the Hypnotherapists education, training, experience and other qualifications regarding the services to be provided.

Name or Responsible Party

Signature

My Products

Product Name

$ Free

Total

$0.00