Client Intake Form

Date

Full Name

First NameLast Name

Preferred Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

This number is my

Birthdate

Date

Gender

Marital Status

Occupation

Have you ever been treated for...? (check all that apply)

Have you ever been treated for an emotional problem? YES or NO. If yes, please explain.

Have you ever been hypnotized before? YES or NO. If yes, please explain.

If we do hypnotherapy, what do you want to accomplish through the use of hypnosis?

Have you made prior attempts to solve the issue(s) we're about to address? If so what were those efforts & what were the outcomes?

Do you have any fears or phobias?

How did you hear about me? (check all that apply)

Other

My signature on this form indicates that I agree and am willing to be guided through a variety of techniques for the purpose of vocational or avocational self-improvement that may include but are also not limited to relaxation, visualization, visual imagery, creative visualization, hypnosis, and stress reduction processes. I understand that if I receive hypnotherapy, it is not a substitute for traditional medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or old illness.

Signature