Hypnotherapy Intake Form- 2023

CONFIDENTIAL CLIENT INFORMATION AND HEALTH HISTORY
Name

First NameLast Name
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Phone (c)
Birth Date:
Email Address
example@example.com
How did you hear about us?
Occupation
Emergency Contact
Phone
Relationship
What would you like hypnotherapy to help you with?
How much water do you drink in a day?
Do you consider yourself stressed?
Any history of schizophrenia?*

YesNo
Any history of seizure disorders?*

YesNo
Please list any conditions that currently affect you or that you have experienced within the last 2 years
Please list any medication (vitamins, herbs, or pharmaceutical) taken now or at regular intervals, include an explanation of what the medication is used to treat.
All of the information provided in this intake form is accurate and true to the best of my knowledge. I understand that Hypnotherapists do not diagnose disease or prescribe medications. I further understand that hypnotherapy is not a substitute for medical attention and examination. I take full responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health.
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