Hypnosis Intake Form

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.
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

Other
Marital Status

Other
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?
Height
Weight
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.

Other
What is your job?
What is your job?
Is there any other information/concerns you would like me to know?
Appointment

Initial appointment deposit

session deposit

$100.00

Total