Clinical Hypnotherapy Intake Form
If your answers do not fit, please write them in an email, on paper or send in text. They will be received at: Wardsclinicalhypnotherapy@yahoo.com and 6312585996.
Name
First Name
Last Name
Address
Street Address
Street Address Line
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Appointment
Emergency Contact
Name
Contact Information
Employer and Occupation
Have you ever used Hypnotherapy Services before? If so, by whom? What types of therapy have you used?
Do you consider yourself stressed? How much water do you drink a day?
List any and all medications and vitamins taken at currently at regular intervals:
List any condition that has effected you within the last few years:
Check any that apply to your Musculoskeletal system:
Fibromyalgia
TMJ
Pain
Other: FILL IN THE BLANK ____________________________________________________
Continue writing here:
Check any that apply to your Respiratory System:
Asthma
Trouble Breathing
Dizziness
Other: FILL IN THE BLANK __________________________________________________
Continue writing here:
Check any that apply to your Circulatory System:
Anemia
Heart Condition
Hypertension
Other: FILL IN THE BLANK ______________________________________________________________
Continue writing here:
Check any that apply to your Digestive System:
Ulcers
Irritable Bowel Syndrome
Colitis
Indigestion
Other: FILL IN THE BLANK ________________________________________________________
Continue writing here:
Check any that apply to your Nervous System:
Spinal Cord Injury
Seizure Disorders
Numbness/Tingling/Twitching
Restless Leg Syndrome
Other: FILL IN THE BLANK _____________________________________________________________
Continue writing here:
Check any that apply to your other conditions:
Anxiety
Social Discomfort
Rage
Panic Attacks
Frequent Headaches
Sleep Disorders
Other: FILL IN THE BLANK _________________________________________________________
Continue writing here:
What brought you in? How long has it been going on? Does it get better or worst with time?
How big of a problem is it in your life on a scale of 1-10? (10-needs to be fixed yesterday.)
If you have success with this, what would it look like to you?
Is there anything else you believe we should know?
Referred by:
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. Signed and Dated. Signature and date below:
Signature
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. Signed and Dated:
Appointment
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