Hypnotherapy Initial Consultation Questionnaire
Personal Information:
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
Marital Status
*
Please Select
Single
Divorced
Married
Widowed
Other
Gender Identification
*
Spiritual and Emergency Contact
Are you a spiritual person?
*
Yes
No
Unsure
I believe in a higher power
This is the only life I live
Occupation
*
Name of Spouse/Significant Other/NA
*
Children's Names & Ages
*
Emergency Contact Name
*
Emergency Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about SoulisticBloom/Who referred you?
*
Medical History
Have you ever been treated for (optional, not disclosed unless required by law)
*
Diabetes
Heart Condition
Cancer
Epilepsy
Aches/Pains
Allergies/Asthma
Phobias**
Anxiety**
Clinical Depression**
OCD*
NPD*
Bipolar Disorder*
Borderline Personality Disorder*
Schizo-Affective type Disorders*
Other persistent problems or conditions
**Work only with referral and release *Do not work with clients with this diagnosis May need referral for all others
In the past year, have you/are you currently seeing a doctor for medical and/or emotional reasons?
*
Please Select
Yes
No
List medications/purpose/NA
*
Do you drink alcohol
*
Please Select
No
Yes, in moderation
Yes, more than I should
Do you abuse drugs/medication
*
Please Select
Yes
No
Recent Life Events
Have any of these events occurred in the past year, are occurring, or will in the next 6 months?
*
Deaths
Job lost/change
Move
Marriage
Divorce
Child leave home
Birth
Accident
Miscarriage
Abortion
Per death
Other
Current Emotional State
Are you experiencing any excessive
*
Anger
Guilt
Sadness
Loneliness
Boredom
Inadequacy
Stress
Frustration
Sympathy
Other
Issues to Resolve
What issues are you interested in resolving?
*
How long have you been affected by this issue?
*
Why are you addressing this now?
*
In what ways have you tried to address this before?
*
How has this impacted your life in the past? (missed events, money, rela tionships, etc)
*
How much time and money have you invested in attempting to resolve this issue?
*
What people/places/events/things have gotten or could get in the way of your success?
*
How would life be different if this was solved?
*
What if nothing changes?
*
On a scale of 1-10, how committed are you to resolve this problem?
*
Please Select
1
2
3
4
5
6
7
8
9
10
Why do you think I should work with you?
*
What else should I know?
*
List at least five specific positive benefits that you would like to gain from working together:
*
Confirmation of Agreement
I have read the Welcome Letter / I Understand the {Bill of Rights} (I have read the Bill of Rights, or if I am a parent, Bill of Rights for Minors)
Confirmation of Agreement
*
Yes
Cancellation Policy:
We have a 48-hour cancellation policy for all appointments. You will not be charged if you cancel or reschedule with at least two business days (Monday-Friday) notice. For example, for a Monday appointment, notify us by Thursday during office hours to avoid charges. Cancellations within 48 hours, missed appointments, or same-day reschedules will incur a fee for the reserved time. Please arrive 5 minutes early for online sessions to test your microphone and connection; late arrivals forfeit that time. We may occasionally run late, but you will always receive your full allotted time.
By submitting this form, you acknowledge and agree that the information contained here is complete and accurate and that you understand our policies.
Print and Email this form, or click Submit and schedule your appointment
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