New Client Intake
Contact Information
Name
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First Name
Last Name
Preferred Name
Date of Birth
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
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example@example.com
Phone Number
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Location
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Street Address
Street Address Line 2
City/Town
County
Postal Code
Emergency Contact
Name
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First Name
Last Name
Relationship
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Phone Number
*
-
General Information
Occupation / Previous Occupation
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Retired?
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Yes
No
Currently in a relationship?
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Yes
No
Partner's first name?
Do you have children?
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Yes
No
Children's first name(s) and age(s)?
Previous experience of hypnotherapy?
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Yes
No
Please give details
Main Issue
What is your primary reason for seeking hypnotherapy with Kim Sweetland?
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Goal
What goals or outcomes would you ideally like to achieve through hypnotherapy?
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Physiological Information
When you feel stressed/worried does it mainly affect your
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Head
Stomach
Both
Do you suffer from particularly bad headaches/migraines?
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Yes
No
Please give details of frequency, severity and if/how it affects your daily life
Do you have a tendency to recheck things?
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Yes
No
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?
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Yes
No
Do you drink alcohol?
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Yes
No
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?
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Yes
No
Ex-Smoker
Do you take recreational drugs?
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Yes
No
Ex-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?
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Yes
No
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?
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Yes
No
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?
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Yes
No
How many nights in an average week do you struggle?
Do you wake during the night?
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Yes
No
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?
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Yes
No
How many mornings in an average week do you struggle?
Do you wake too early in the morning?
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Yes
No
How many mornings in an average week do you wake too early?
Health Care Information
Are you taking any medications?
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Yes
No
Please detail
Health Care Provider
Please list any known medical diagnoses
Client Information Agreement
Accuracy of Information
*
I confirm that all the information provided is true and correct to the best of my knowledge. I will inform Kim Sweetland Hypnotherapy if any of the information I have provided changes during the time we are working together.
Please read my
Privacy & Data Protection Policy
.
Privacy Policy acknowledgement
*
I confirm that I have read and understood the Kim Sweetland Hypnotherapy Privacy & Data Protection Policy, which explains how my personal information is collected, used, stored and protected.
Explicit consent for sensitive information
*
I explicitly consent to Kim Sweetland Hypnotherapy processing the information I provide about my physical and mental health, medical history and any other special category personal data relevant to providing me with Solution Focused Hypnotherapy, as explained in the Privacy & Data Protection Policy. I understand that I can withdraw this consent at any time.
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Signature
*
Submit
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