• The Clear Insight Intake Form

    Please fill out the sections accurately to help us understand your background and goals.

  • Client Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*

  • Emergency Contact

  • Format: (000) 000-0000.

  • Lifestyle

  • How much water do you typically drink per day?
  • How would you rate your current stress level?

  • Previous Experience

  • Have you experienced hypnotherapy before?*
  • Have you experienced psychotherapy or counseling before?*
  • Have you ever been diagnosed with schizophrenia?*
  • Have you ever been diagnosed with epilepsy or a seizure disorder?*

  • Medications & Health History

  • Health History

  • Musculoskeletal
  • Respiratory
  • Circulatory
  • Digestive
  • Nervous System
  • Other Conditions

  • Goals for Hypnotherapy

  • Agreement & Consent

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I acknowledge that the information provided is accurate and complete to the best of my knowledge. I understand that hypnotherapy is not a substitute for medical or psychological treatment and that results are not guaranteed. I consent to participate in hypnotherapy sessions and understand that my information will be kept confidential.
  • Questions? We’re Here to Help. If you have any questions about this intake form, please contact Bree at 916-877-0146 or ClearInsightWay@gmail.com. I’ll be happy to walk you through it.
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