StepStone Hypnosis Client Intake Form 2022

Tamelynda Lux | Lux & Associates (est. 1988)
PO Box 29061 London, Ontario Canada N6K 419 | 519-670-5219
info@TamelyndaLux.com | www.StepStoneHypnosis.com

FaceBook: @TamelyndaLux | Twitter: @TamelyndaLux
CLIENT INTAKE FORM
Name*

First NameLast Name
Your pronoun (she/her, he/him, they/them)*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Permission to contact you (yes/no)blanks* . Preferred method (email or phone)blank .
May I also contact you by regular postal mail?*
Marital / Living Status*

SingleLiving with someoneMarriedSeparatedDivorcedOther
Name of Significant Other & How long together
People living with you (first name, relationship, age)
More About You . . .
Please indicate which of the following applies to you:*

ReligiousSpiritualPhilosophicalOther
When calling out to a higher being, how do you refer to it? For example, God, Buddha, the Universe. *
Please list any medical issues and history, including current medications that may be relevant to the issue you are wishing to resolve:*
Please list any CURRENT medical/specialist support you are receiving (or have received) that may be relevant (ie. counselling, psychotherapy, AA/Al Anon/support groups, pastor etc.)*
Please list any PAST (within last 5 years) medical/specialist support you have received, how long treatment, for what, and how long since last appointment (ie. counselling, psychotherapy, AA/Al Anon/support groups, pastor, etc.).*
Please indicate any of the following concerns you would like to address during this or subsequent sessions:*

Study skills/test anxietyPhysical health issuesWeight control/Eating habitsSmokingAllergiesSkin issuesSleep ProblemsMemory EnhancementAbuse (sexual or other)Stress managementGrief, Loss, BereavementSexual issuesGamblingAlcohol / Drug dependencyPain managementFeeling stuckAnxiety / PanicRelationshipsOther
How did you hear about my service?*
Have you been hypnotized before?*

YesNo
If yes, how did it go? What were the results?*
SPECIFIC reason/one main topic for coming for hypnosis?*
What attempts have you made before to address this issue?*
What is the behaviour you wish to change?*
List 5 benefits of changing this unwanted behaviour. In other words, what does SUCCESS look like, feel like, or experience like?
1.*
2.*
3.*
4.*
5.
What internal conflict may be causing all (or part) of this problem?
What past or current relationship may be causing the issue?

Client to acknowledge they have read, understand, and agree to each of the following statements:*

	Agreed
I am in charge of my mind, and therefore my results. Mind and body form a linked system.
My mental attitude affects my body and my health and, in turn, how I behave. If what I am doing isn't working, do something else.
Flexibility is key to success.
We are always communicating. Even when we remain silent, we are communicating. Non-verbal communication can account for a large proportion of a message.
It is my interpretation and response that reflects the effectiveness of any suggestion.
There is no failure, only feedback. What seemed like failure can be thought of as success that just stopped too soon. With this understanding I can find solutions and improve the quality of what I do.

Technology Section for Online Zoom Hypnosis Sessions

You can skip this section if you are meeting Tamelynda in person for your session
Type of technology:

Desktop computerLaptop or TabletCell phoneBuilt in webcamExternal webcam
For ONLINE Hypnosis, please describe your set-up.
Type of camera

Built-in on deviceExternal to device
Type of speaker

Build-in on deviceExternal to device
Type of audio

HeadsetBuilt-in speakersExternal speakersEar buds
Please describe your environment

At homeOffice (traditional work environment outside of home)Safe, Quiet, and UninterruptedReclinerSofaBed (must be sitting upright)Other
Final Section
All information shared is held in strict confidence. It is imperative that the hypnosis client and the practitioner share a strong sense of trust. If there is anything further you wish to discuss with Tamelynda Lux before the sessions or any boundaries you would like to establish to ensure your comfort and relaxation, you are encouraged to bring this/these to my attention before the first session.

I, Client, have completed this Client Intake Form to the best of my knowledge and I have disclosed any mental or physical health problems that may be pertinent to the safe facilitation of a hypnosis session.
Client Signature*

Clear
Date*

MonthDayYear
Date
(C) 2023 Lux & Associates | Tamelynda Lux | StepStone Hypnosis & Hypnotherapy
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CLIENT INTAKE FORM

More About You . . .

Technology Section for Online Zoom Hypnosis Sessions

Final Section