Kim Sweetland Hypnotherapy - New Client Intake Form

New Client Intake
Contact Information
Name*

First NameLast Name
Preferred Name
Date of Birth*

DayMonthYear
Date
Age*
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Emergency Contact
Name*

First NameLast Name
Relationship*
Phone Number*
General Information
Occupation*
Retired?*

YesNo
Currently in a relationship?*

YesNo
Partner's first name?
Do you have children?*

YesNo
Children's first name(s) and age(s)?
Previous experience of hypnotherapy?*

YesNo
Please give details
Main Issue
What is your primary reason for seeking hypnotherapy with Kim Sweetland?*
Goal
What goals or outcomes would you ideally like to achieve through hypnotherapy?*
Physiological Information
When you feel stressed/worried does it mainly affect your*

HeadStomachBoth
Do you suffer from particularly bad headaches/migraines?*

YesNo
Please give details of frequency, severity and if/how it affects your daily life
Do you have a tendency to recheck things?*

YesNo
Please give details of the things you tend to check, the frequency and if it affects your daily life
Do you bite your nails/chew the skin on your fingers or pick your skin?*

YesNo
Do you drink alcohol?*

YesNo
Please describe your relationship with alcohol (frequency, rough amounts, if/how it affects your life, do you consider it a problem?)
Are you currently a smoker/vaper?*

YesNoEx-Smoker
Do you take recreational drugs?*

YesNoEx-User
Please describe your relationship with recreational drugs (type, frequency, if/how it affects your life, do you consider it a problem?) - Your answers are completely confidential, but your honesty could help how we approach your journey
Do you have any specific fears or phobias?*

YesNo
Please describe your fears/phobias and how/if they impact your life (do they cause you to avoid things for example)
Do you think you have ever experienced a panic attack?*

YesNo
Please describe your last panic attack, including the trigger (if known) and when it occurred. How often you experience these episodes and do you know specific triggers?
Sleep Information
Do you have difficultly getting to sleep?*

YesNo
How many nights in an average week do you struggle?
Do you wake during the night?*

YesNo
How many nights in an average week do you wake and roughly how long are you awake for?
Do you have difficultly waking/rising in the morning?*

YesNo
How many mornings in an average week do you struggle?
Do you wake too early in the morning?*

YesNo
How many mornings in an average week do you wake too early?
Health Care Information
Are you taking any medications?*

YesNo
Please detail
Health Care Provider
Please list any known medical diagnoses
Client Information Agreement
I confirm that the information I have provided is accurate and complete. I acknowledge that it is my responsibility to inform Kim Sweetland Hypnotherapy if any of my answers change during our time working together. I understand that providing false or incomplete information may impact my results.
Date*

DayMonthYear
Date
Signature*
Should be Empty:

New Client Intake

Contact Information

Emergency Contact

General Information

Main Issue

Goal

Physiological Information

Sleep Information

Health Care Information

Client Information Agreement