Hypnosis Intake Form for Keala Robb Hypnosis

Client Information and Hypnosis Intake Form

Keala Robb Hypnosis
Client's Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Legal Guardian's Name if applicable

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Gender

MaleFemaleOther
Marital Status
Children's ages
Do you wear contact lenses? During hypnosis your eyes will be closed for about 45 minutes. If your contacts will cause eye irritation, you may want to remove them before the hypnosis session begins.

YesNo
Hearing Problems? If you wear hearing aid, please use them during your session.

YesNo
Thank you for helping me promote my services. How did you hear about me?

InternetFlierInstagramFacebookBusiness CardClient or Physician Referral*Other
*May I send them Thank you?

YesNo
First Name Last Name Street Address Address Line 2 City State Zip Email
Have you had prior experience with hypnosis?*

IndividualGroupStage ShowNone
If yes, please describe experience and results.
Primary goals for hypnosis?*

Stress ManagementSmoking CessationSleep ImprovementConfidenceSelf Esteem/Self ImagePositive ThinkingStudy SkillsHabit Control (Anger, Nail biting, Substances ect.)Weight ManagementMotivationGoal AchievementRelationshipsHealthy AttitudeAbundant ManifestationPast Life RegressionOther
Describe
Brief Medical History
Are you under a Physician's care for any medical conditions or illnesses?*

YesNo
If yes, for what condition ?
Doctor's Name
Have you had a physical in in the last year?*

YesNo
Please list any significant health issues and current or past hospitalization.
Have you ever been diagnosed with any of the following?

DepressionPost Traumatic Stress Disorder (PTSD)SchizophreniaAnxietyBipolar or Manic DepressiveDiabetesOther
Details
Current Medication
Prescribing Doctor
Are you under the care of a Mental Health Professional?*

YesNo
If yes, for what?
Doctor's Name
What are your spiritual/religious beliefs and or practices?*
Please describe the nature of your work or profession.*
Please briefly share anything else that would be helpful to know about you, (i.e., recent life-changing events such as death, divorce, job changes, moving, etc.)
Emergency Contact*

First NameLast Name
Emergency Contact Phone number*
Please enter a valid phone number.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Client Information and Hypnosis Intake Form

Brief Medical History