NEW CLIENT
To ensure the most effective coaching or therapeutic relationship possible, this questionnaire is designed to help identify key themes, treatment goals, and preferred strategies catered to your needs. Please fill out the entire questionnaire to the best of your ability and comfort level before our first session. Don't worry, this is just a starting point – we can always delve deeper and modify your treatment goals as needed throughout our sessions.
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Emergency Contact Name
Emergency Contact #
Describe the goals or outcomes you hope to achieve:
Have you ever been through Hypnotherapy before?
Yes
No
List any fears or phobias that you have:
Describe the places, real or imaginary, that relax you and put you at peace:
Which of the following issues currently affect your life?
Anxiety
Physical Health
Life Changes
Loss of Self
Sleep
Perfectionism
Work
Relationships
Inadequacy
Lack of Focus
Depression
Racing Mind
Grief/Loss
OCD
Stress
Addiction
Phobias
Finance
Fear of Death
Fear of Rejection
Fear of Failure
Finances
Other
Share any other issues, recent life-changing events, or any other information that would be helpful for us to know about:
Have you been treated by a doctor and were given consent to undergo Hypnotherapy?Have you ever been through Hypnotherapy before?
*
Yes
No
Disclaimer
Jennifer Vig is not a Licensed Doctor or Mental Health Professional. All clients seeking sessions for pain or that have a diagnosis for treatment of any kind from a Licensed Medical processional, is required to have a referral from a licensed practitioner of healing arts. All services listed on this site and performed either in person or virtually, are not intended to take the place of medically licensed care and should not be considered a substitute for such care, nor should the sessions be considered "treatment" for a condition - diagnosed or not. Jennifer Vig works specifically with symptoms - not diagnosis'. While Nebraska does not currently (2024) have specific statutes pertaining to the practice of Hypnotherapy, Jennifer Vig guarantees that all interactions will be conducted in or above the highest standards in the art of Hypnotherapy, both ethically and legally.
Client Signature
Date
-
Month
-
Day
Year
Date
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