Complex Trauma Intake Form - Soul Solace Hypnotherapy

Complex Trauma Client Intake Form

Trauma Protocol
Date

DayMonthYear
We invite you to complete this intake form with honesty and openness, knowing that everything you share is held in the strictest confidence. Your information is never shared outside of this practice and is used only to support your care. By being transparent, you allow us to understand your needs more fully and create a safe, supportive space for your journey. Your trust is deeply valued, and this form is part of building a respectful and caring partnership together
Patient Information
Full Name

First NameLast Name
Age
Gender

MaleFemale
Mobile Number *

Area Code +61Phone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState

Postal
Employment Status
Employed, Self-employed, unemployed
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
What is your primary Concern (symptoms, duration, intensity) What do you feel is holding you back the most from living a fullfilled life?
What are you wishing to achieve for yourself?
Your life
Any significant traumas in your life since you were born. Were you ever physically hurt as a child by a parent or other adult?
Were you ever humiliated as a child by a parent or other adult?
Did you feel unloved as a child?
Did you have a parent or guardian who was an alcoholic or drug addict:
Was a biological parent ever lost to you by divorce, abandonment, or death before the age of 10?
Do you fear any of the following?

HeightsWaterThe DarkInsectsAnimalsBeachesConfines spacesGerms
Mental Health Check
Flashbacks (where you feel dissociated or totally lose touch with surroundings)

YesNo
Intrusive Memories (Where you can’t put something upsetting out of your mind

YesNo
Angry outbursts (where you find it hard to control your irritation/temper)

YesNo
Startle Reaction (loud noises/fireworks etc) or feeling jumpy

YesNo
Difficulty sleeping (Difficulty falling asleep or insomnia)

YesNo
Nightmares

YesNo
Recurrent dreams of one or more incidents

YesNo
Difficulty concentrating

YesNo
Hyper vigilance (Being very aware of potential danger)

YesNo
Feelings of Isolation, Active attempt to isolate yourself from others

YesNo
Unexplained pains or paralysis anywhere in your body. Say where.

YesNo
Rollercoaster emotions which can change very quickly

YesNo
Feeling emotionally numb

YesNo
Avoidance of social situations

YesNo
Racing thoughts

YesNo
Gaps in your memory of important events

YesNo
Tendency towards negative thoughts rather then positive

YesNo
Unexplained physical symptoms such as heart pounding, sudden sweating, difficulty breathing

YesNo
Loss of interest in activities you used to enjoy

YesNo
Worries about dying prematurely

YesNo
Desire to commit suicide

YesNo
Any current or history of violent behavior? If yes, please explain below when, how, and what happened.
Do you have any past or current medical condition (physical) that you would like to list? (head injury, accident, etc.)
Is there any previous hospitalization? If yes, please explain the reason. If no, leave blank
Operation/Surgury of any kind
Have you been diagnosed for Post Traumatic Stress Disorder. If yes, by what type of practitioner?
Psychologist, Psychiatrist, Doctor
When was this diagnosed
Treatments you have had for PTSD to date?
Has PTSD got worse or better since diagnosis & treatment:
Do you suffer any of these Physical Conditions

Low Blood PressureHeadachesIBSHigh Blood PressureThyroid ProblemsSkin ConditionsFibromyalgia
Do you do any of the following, or have you ever done any of the following?*

SmokeUse Marijuana or CocaineUse Heroin/LSDThyroid ProblemsDrink to numbFibromyalgia
The reason I ask is to get an idea of how much you are having to self-medicate. Also if you use Heroin or LSD it makes you go into hypnosis very quickly, so it is good for me to know that
Current Medications

Medications you are taking for PTSD/Insomnia, Depression, Weightloss etc (including cannabis oil)
What emotion(s) do you feel about yourself right now?
List your greatest strengths?
Describe the activity which makes you most relaxed and happy?
Describe how you want your life to be in one year from now?

Medications (If needed)

	Medication name	Purpose
1
2
3
4
5
6
7

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Complex Trauma Client Intake Form

Patient Information

Your life

Mental Health Check

Current Medications