CONFIDENTIAL QUESTIONAIRE
Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Second Phone:
Format: (000) 000-0000.
Email:
example@example.com
Age:
Sex:
Height:
Weight:
Date of Birth:
-
Month
-
Day
Year
Date
Occupation:
Favorite Hobbies:
Marital Status:
Single
Married
Divorced
Widow/Widower
What benefit do you want from hypnosis?
Please briefly describe the nature of your problem:
How long have you had this problem?
What is the most difficult part of eliminating your problem?
Do you have any concerns about hypnosis?
Yes
No
If Yes, please explain:
Is eliminating your problem a priority for you?
Yes
No
Does your problem affect you when you are under stress?
Yes
No
Do you feel your problem controls you?
Yes
No
Are you embarrassed by your problem?
Yes
No
Does your problem affect you professionally?
Yes
No
Does your problem affect your social life?
Yes
No
Does your problem affect your activities?
Yes
No
Does your problem make you feel tired and run down?
Yes
No
Do you exercise?
Yes
No
If Yes, what type:
How often:
Are you currently under the care of a physican?
Yes
No
If Yes, Physician's Name:
Did your doctor recommend that you use hypnosis?
Yes
No
To the best of my knowledge, all of the above information is true and correct. I willingly allow Rebekka Putnam to use this information to help me decide if hypnosis, EFT, or Reiki can benefit me. I understand that my entire client file will remain completely confidential unless I request otherwise in writing, except as provided for by law. I would like to receive your email newsletter.
Signature:
Date:
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: