Confidential Intake Form

Confidential 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.
All fields marked with an asterisk* are required.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemaleOther
Employer
Occupation
Emergency Contact *
Relationship*
Phone number*
Marital Status

MarriedRe-marriedEngagedSeparatedDivorcedWidowedSingleOther
Please list any conditions that currently affect you, or that you have experienced in the last 2 years.*

AnemiaAsthmaAnxietyDizzinessFibromyalgiaHeadachesIndigestionIrritable Bowel SyndromeHeart ConditionHypertensionInsomniaNumbness/Tingling/TwitchingPainPanic AttacksTMJTrouble BreathingUlcersNoneOther/Not listed
Please describe.
How much water do you drink per day?
Do you consider yourself stressed?
Have you every used the services of psychotherapy? If yes, by whom and when?
Have you ever been diagnosed with schizophrenia?*
Have you been diagnosed with Epilepsy or have you had a Seizure in the last 2 years? (If yes, hypnosis is contraindicated except in a clinical setting with medical supervision.) *
Prior experience with hypnotherapy?

YesNo
What do you hope to achieve with hypnotherapy?
Give a brief account of the history and development of your issues.
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. (Vitamins, Herbs and Pharmaceuticals)
How are your sleeping patterns? How many hours do you average per night?
Check areas where any problems may exist.

ChildrenFriendsSexAffairsCommunicationWorkFinancesSubstance abuseRecreation/leisureReligious differencesArgumentsVerbal abuseIn-lawsPhysical abuseOther
Is there any other information and/or concerns that you would like for me to know about?
All of the above 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.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Confidential Intake Form

All fields marked with an asterisk* are required.