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

Address

Street Address Line 2

CityState / Province

Zip
Age*
Birthdate*

MonthDayYear
Date
SDSep.Wid.Married
If children, what are their ages?
Occupation*
Highest education level completed*
Doctor’s Name*
Phone*
Format: (000) 000-0000.
Complete Address
YesNo
( A ) Indicate any current health problems
( B ) Indicate any medications being taken & their purpose
Emergency Contact*
Phone*
Format: (000) 000-0000.
NoYes
NoYes
NoYes
NoYes
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?*
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?*
NoYes
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
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*

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Date*

MonthDayYear
Date
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