Hypnosis Intake Form
The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and as accurately as you can, you will assist me in maximizing your time and saving you money.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Prior experience with hypnotherapy?
What do you hope to achieve with hypnotherapy?
Give a brief account of the history and development of your complaints.
Do you have any fears? Please explain them in a detailed way.
Current health status
List illnesses and injuries.
List any medications you are taking.
How are your sleeping patterns?
Relationship with father
Relationship with mother
Number and Gender of Siblings
Relationship with brother’s/sister’s
List children and ages with a short personality description of each.
Check areas where problems exist.
What is your job?
Is there any other information/concerns you would like me to know?
Type a question
Should be Empty:
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