New Client Intake
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
Age
Status
Please Select
Single
Married
Divorced
Widowed
Other
Number of people living with you?
Relationship, Names & Ages of people living with you
Healthcare Provider (Name & Number)
Occupation
Religious Preferences
Pets & Their Names
Hobbies
Phobias (if any)
Please list any medical issues and history, including current medications that may be relevant:
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Please circle any of the following issues you would like to address during this or later sessions:
Study Skills/Test Anxiety
Physical Health Issues
Trauma
Weight Control/Eating Habits
Sleep Problems
Anxiety/Panic
Anger/Stress Management
Grief/Loss
Feeling Stuck
Smoking/Tobacco Alcohol/Drug
Allergies
Skin Issues
Pain Control
Memory Enhancement
Relationships
Development
Finding or Clarifying Your Life Purpose/Passion
Other
All information shared is held in strict confidence. It is imperative that the hypnosis client and the therapist share a strong sense of trust. If there is anything further you wish to discuss with me before the sessions or any boundaries you would like to establish to ensure your comfort and relaxation, I encourage you to please bring this to my attention.
I have completed this Client Intake Form to the best of my knowledge and I have disclosed any mental or physical health problems that may be pertinent to the safe facilitation of a hypnosis session.
Client Name (Print)
First Name
Last Name
Signature
Parent/Guardian Name (Print)
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Agree
Agree
Should be Empty: