Client Intake Form for Addictive Behaviors

Client Intake Form for Addictive Behaviors

The answers you provide in this form will help uncover the deeper patterns and experiences connected to the behaviour you would like to change. Please answer each question openly and thoughtfully, giving yourself a moment to reflect before responding. Your honesty allows your hypnotherapy sessions to be tailored specifically to you, creating the best possible environment for lasting change. All information is treated with complete confidentiality.
Date*

DayMonthYear
Date
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

CityState / Province

Postal / Zip Code
Occupation *
Relationship Status? *
Eg. Married 7 years, 3 Children
Have you experienced hypnosis before? If yes, what was the experience like?*
What did you use it for? Was it successful?
AlcoholSmoking/TobaccoDrugs (prescription or illicit)GamblingPornographySocial Media/TechnologyFoodShoppingOther
If yes to Alcohol - What type of alcohol do you drink most?*
Beer, Wine, Spirits, Mixed Drinks
If yes to drugs - Please list types and amount of use*
Eg. I use Marijuana, 1 Joint a night
If more than one box ticked, which one is to be prioritized?*
Eg. I have an Issue with Marijuana and alcohol, but I need to stop Alcohol first as that is linked to the alcohol
MorningAfternoonEveningLate nightOnly Socially, but BingeOther
StressAnxietyAngerLonelinessBoredomSocial environmentsHabit / routineFeeling unworthyShameFeeling rejected
When you feel the urge, what does your mind usually say to you?*
"Just one won't hurt", "I deserve this", "This will help me relax."
What does this behaviour give you in that moment?*
Relief, Escape, Comfort, Confidence, numbing feeeling, feeling accepted, feeling in control, distraction
What feelings are present after the behavior?*
Eg. I feel sluggish, tired, disconnected, shame, guilty
How often do you engage in the selected behavior(s)?*
How old were you when you were first exposed to this behavior or substance? Where were you? Who were you with? Describe the situation in detail. What emotions did you feel at that moment? Excited, Nervous, Accepted , Rebellious, Curious, Escaping something?*
Did anything significant happen in your life around that time?*
Eg. School, Bullying, Peer pressure, Parents seperated
When did this behavior begin to increase? What life events were happening at that time?*
Eg, Relationship issues, Loss or grief, Trauma, Stress at work, Mental health struggles?
Loss of a loved oneDivorce or separationChildhood traumaEmotional neglectAbuseMajor life stressSerious illness
Would you like to briefly describe this experience?*
Did anyone in your family struggle with addiction? If so, who and how was alcohol/substances used in family gatherings?*
Alcohol, Drugs, Gambling, Food, Smoking
How would you describe your childhood? Did you feel emotionally supported as a child?*
Eg. Stable, Chaotic, Strict, Loving, Emotionally distant, Abusive
YesNoNo, I'm scared of failure
If yes, please describe what you tried and the outcome.*
The following questions help identify patterns and experiences that may be influencing current behaviours. There are no right or wrong answers.
What is your biggest motivation to change? What might make change difficult? What made you decide to seek help now?*
Health fears, Feeling out of control, Risk of losing relationships, job etc.
What would success look like for you? How would your life change?*
How would you describe your current relationships? Do you feel emotionally supported? Have relationships been affected by this behaviour?*
How do you usually cope with stress? Current life stressors?*
Eg. Exercise, Alcohol/substances, Food, Isolation, Talking to others.
Heart DiseaseAllergiesMental Health Conditions, DepressionPTSDInsomniaChronic PainAnxiety, Panic AttacksADHD or AutismOther
If other, please list here
Medications. Please provide details about any medication you are taking and what they are treating?*
List all over the counter and prescription medication
Complete the following statements:*
I drink/use because…
When I try to stop I feel…
A part of me believes I need this because…
Without this behaviour I am afraid that…
"I am the type of person who…"
"I wish I could stop but…"
"If I truly changed my behaviour, my life would…"
What personal qualities do you have that could help you change?*
Imagine one year from now and this issue is completely resolved. How would you feel waking up each day without this problem?*
What does your life look like?
How motivated are you to change this behavior?*

1

2

3

4

5

1 is Not motivated, 5 is Very motivated
If the part of you that drinks/uses could speak, what would it say it is trying to protect you from?*
When you imagine completely stopping this behaviour, what concerns or fears come up for you?
I worry I will feel stressed or overwhelmed, I worry I will feel bored, I worry I will lose part of my identity, I worry I will replace it with another behaviour, I worry I will struggle socially
Is there anything you feel your hypnotherapist should know about you that has not been asked here?
Safety Screening (Important for Hypnotherapy - Contradictions)

Psychosis, Schizophrenia, Bipolar manic episodes, Epilepsy / seizures

If YES → conditional message:

Please note that hypnotherapy WILL require medical clearance before sessions proceed.
Client Agreement: By signing below, I acknowledge that I have read and understood the hypnotherapy process and commit to participating fully and honestly in the sessions.
Informed Consent & Client Agreement
I understand that clinical hypnotherapy is a complementary therapeutic approach designed to support behavioural and emotional change. While hypnotherapy can be a powerful tool for accessing subconscious patterns and facilitating change, results cannot be guaranteed.

I acknowledge that lasting change requires my active participation, conscious effort, and commitment both during and outside of sessions. Hypnotherapy is not a passive process, and my willingness to engage honestly and apply the insights and strategies discussed is an important part of achieving successful outcomes.

I understand that addressing addictive behaviours often involves changing habits, emotional responses, and thought patterns that may have developed over time. I acknowledge that progress requires personal responsibility, consistency, and openness to the process.

I agree to answer all intake questions honestly and to communicate openly during sessions so that my hypnotherapist can work safely and effectively. I understand that withholding relevant information may affect the effectiveness of treatment.

I understand that clinical hypnotherapy does not replace medical, psychological, or psychiatric care. If I have any medical or mental health conditions, I will continue to seek appropriate professional care and inform my practitioner of any relevant diagnoses or medications.

By signing below, I confirm that I voluntarily consent to participate in hypnotherapy sessions and understand my role and responsibility in the process.
Client Signature*
Should be Empty: