MTU Hypnosis - Client Intake Form

MTU Hypnosis - Client Intake Form
Name*
Home Phone
Cell*
Work
Accept Texting?*

YesNo
E-mail*
example@example.com
Address*

Address

Street Address Line 2

CityState / Province

Zip
Age*
Birthdate*

MonthDayYear
Date
Marital Status*

SDSep.Wid.Married
If children, what are their ages?
Occupation*
Highest education level completed*
Doctor’s Name*
Phone*
Complete Address
Are you under a doctor’s care now?*

YesNo
( A ) Indicate any current health problems
( B ) Indicate any medications being taken & their purpose
Emergency Contact*
Phone*
Do you have light sensitive epilepsy?*

NoYes
Do you wear contact lens?*

NoYes
Dentures?*

NoYes
Have you ever been psychologically treated for an emotional/behavior problem?*

NoYes
Provider name
Phone
Complete Address
Why are you seeking hypnotherapy?*
What do you think is the cause of the issue/problem?*
What previous efforts, if any, have you taken to solve this problem?*
What makes you happy?*
Have you ever been hypnotized?*

NoYes
Number of times?*
If hypnotized before: indicate private or group/purpose/result?
Do you have any fears, concerns, or questions about hypnosis? *
How did you find MTU Hypnosis?*
Do you know anyone personally who used hypnosis to improve or change his or her life?*

NoYes
Select the most important element in deciding to use our services.*

Effectiveness ( your results )Service ( how we respond to your needs )Time ( how fast you get results )Affordable ( what we charge )
List your e-mail address if you are interested in receiving our e-newsletter
example@example.com
What are 3 -5 positive benefits you get by eliminating your problem? Example: I am more relaxed and at ease even when dealing with stressful situations.
a*
b*
c*
d
e
Where applicable, check the issues you have been dealing with and/or would like to resolve.*

AlcoholismAngerAnxiousBed WettingCancer/Chemo/RadiationDrug AddictionFear of Flying/HeightsFeeling OverwhelmedGagging ReflexGamblingHabit ControlHigh Blood PressureIBSImproved ConcentrationInfertilityInsomniaJealousyJob Interview AnxietyLearning/ADDMedical/Dental ProceduresMemory ImprovementMigrainesMotivationNail Biting/PickingNervous StomachNervous TicsOCDOrganizational SkillsOver-Healing/ScarringPain ManagementPanic AttacksPerformance AnxietyPre/Post SurgeryProcrastinationPTSDPublic SpeakingRelationship IssuesSalesSelf ConfidenceSkin ProblemsSmoking CessationSports ImprovementStress ManagementStutteringTeeth Grinding/Jaw ClenchingTension HeadachesTest Taking/Study HabitsTime ManagementTobacco ChewingVapingVertigoVisualizationWartsWeight ControlNONEOther
First & Last Name*
Signature*

Clear
Date*

MonthDayYear
Date
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