New Client Intake Form
Accelerate Wellness Hypnotherapy
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Marital Status
Please Select
Single
Married
Divorced
Widowed
Other
Email
example@example.com
Primary Phone
Format: (000) 000-0000.
Preferred Method of Contact
E-mail
Phone
Other
Primary Care Provider Name
First Name
Last Name
Primary Care Provider Phone
Format: (000) 000-0000.
Are you currently taking prescription medication?
Yes
No
Medication/s
Health Problems/Medical Conditions
Emergency Contact Information
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Areas of Concern
Check your areas of concern (3 boxes only)
Addictions
Anxiety/Depression
Achieving Goals
Concentration/Memory
Career issues
Confidence
Depression
Diet/Weight issues
Fears/Phobias
Infertility
Feeling Stuck
Financial wellness
Guilt
Grief
Motivation
Nerves/Exams
Panic Attacks
Procrastination
Public Speaking
Sleep Problems
Religious Hurt/Abuse
Smoking / Drinking
Stress
Other
Additional information about your area of concern
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Therapist Name
First Name
Last Name
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: