Hypnotherapy pre- assessment

Hypnotherapy pre-assessment
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Date of birth

MonthDayYear
Date
Have you ever been diagnosed with Bipolar Disorder, Schizophrenia, Psychosis or Epilepsy?
Are you currently under the care or a Mental Health Team, Psychologist or Psychiatrist?
Are you currently on any medications for your mental health? (SSRI’s, Benzodiazepines, etc)
Do you have any other health conditions? If so, are you on any medication for them? Please give details
Have you received any other treatment/ therapy for your issue/ problem?
Please briefly describe why you are seeking my help- (we will go into a lot more detail in our initial consultation)
Anxiety Measure

OVER THE LAST 2 WEEKS how often have you been bothered by any ofthe following problems?

	Not at all	Several days	More than half the days	Nearly every day	Every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

OVER THE LAST 2 WEEKS how often have you been bothered by any of the following problems?

	Not at all	Several days	More than half the days	Nearly every day	Every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading or watching the television
Moving or speaking so slowly that other people could have noticed – or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or hurting yourself in some way

Over the last 2 weeks-

	None of the time	Rarely	Some of the time	Most of the time	All of the time
I’ve been feeling optimistic about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling close to other people
I’ve been able to make up my own mind about things

Hypnotherapy pre-assessment