MTU Hypnosis - Client Intake Form

MTU Hypnosis - Client Intake Form
Name
Home Phone
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Work
Format: (000) 000-0000.
Accept Texting?
E-mail
example@example.com
Address

Address

Street Address Line 2

CityState / Province

Zip
Age
Birthdate

MonthDayYear
Date
Marital Status
If children, what are their ages?
Occupation
Highest education level completed
Doctor’s Name
Phone
Format: (000) 000-0000.
Complete Address
Are you under a doctor’s care now?
( A ) Indicate any current health problems
( B ) Indicate any medications being taken & their purpose
Emergency Contact
Phone
Format: (000) 000-0000.
Do you have light sensitive epilepsy?
Do you wear contact lens?
Dentures?
Have you ever been psychologically treated for an emotional/behavior problem?
Provider name
Phone
Format: (000) 000-0000.
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?
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?
Select the most important element in deciding to use our services.
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.

Other
First & Last Name
Signature
Date

MonthDayYear
Date
Should be Empty: