Soul Solace Hypnotherapy - Client Intake Form

Current Age*

Full Name*

First NameMiddle NameLast Name

Email Address*

example@example.com

Mobile Number*

Area CodePhone Number

Home Address*

Street Address

Street Address Line 2

CityPostal / Zip CodeCountry

Medical History and Current Issues*

If other, please specify:

If mental Health (Inc. Psychological or Psychiatric) has been ticked above, please provide a brief description of diagnosis, treatment and support received to date.*

Do you drink alcohol or use recreational drugs? If so, what kind and how often? *

Please list any prescription or over-the-counter medications, including dosages and frequency. *

Have you ever been hypnotized before?*

YESNO

If yes, what was the reason and outcome of your previous experience?*

Primary reasons for seeking hypnotherapy?*

Please list what you intend to accomplish through the use of our services?*

Briefly describe any important relationships in your life and how satisfied you are with how they are going.*

Is there anything else that is important for me as your therapist to know about and that was not covered in this form?*

Briefly describe your family of origin (parents, siblings names, ages etc.) and your childhood*

Parents? (Alive, divorced, how is your relationship with them?*

Did you have serious illnesses/injuries OR physical/emotional trauma as a child? If so, and at what age? *

Are there any important aspects of your cultural/ethnic identity that would be important for me to consider as your hypnotherapist?

Consent for Treatment - By attending hypnotherapy sessions at Soul Solace Hypnotherapy, you acknowledge and agree to the following:*

Voluntary Participation: You understand that participation in hypnotherapy is entirely voluntary. You may decline or withdraw from treatment at any time without penalty or prejudice.Nature of Hypnotherapy: You acknowledge that hypnotherapy is a collaborative therapeutic process involving guided relaxation, focused attention, and positive suggestion. While many clients experience beneficial outcomes, results may vary and cannot be guaranteed.Scope of Practice: You understand that hypnotherapy is not a substitute for medical, psychological, or psychiatric treatment. You agree to disclose any current diagnoses, medications, or treatments to ensure safe and appropriate care.Confidentiality: All personal information shared during sessions will be treated with strict confidentiality, except where disclosure is required by law (e.g., risk of harm to self or others).Session Recording & Notes: You consent to the practitioner taking session notes and, if applicable, recording audio for therapeutic purposes. These materials will be securely stored and used only with your permission.Client Responsibility: You agree to engage actively in the therapeutic process and communicate openly with your practitioner. You understand that your commitment and mindset play a vital role in the effectiveness of hypnotherapy.Fees & Cancellation Policy You acknowledge the agreed-upon session fees and cancellation terms, including any charges for missed appointments or late cancellations.

Signature

Client Intake Form

General Health Questions

Present Relationships

Is there something more you wish to share?

Childhood Relationships

Cancellation & Fee Policy