Hypnosis Intake Form

Hypnosis Intake Form

Please complete this intake form as accurately and fully as possible before your hypnosis session.
Client Information
Name
Today’s Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Gender
Address
City
State
Zip
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Job Title
Marital Status
Hypnotherapy Intake
Explain in detail your objective and why you are seeking hypnotherapy
How long have you been experiencing this issue?
What do you believe might be causing or contributing to this?
Describe previous efforts to solve this
Any other issues you wish to address in the future?
Do you have any diagnosed medical or mental health conditions? If YES, please explain
Are you currently taking medications or undergoing other treatments? If YES, please explain
Are you currently receiving counseling? If YES, please explain
Recreational Drug use? If YES, please explain
Alcohol consumption: If YES, average number of drinks per week?
What are your sleep habits? (ex: bedtime, wake time, sleep quality)
How would you describe your stress level on an average day?
On a scale of 1-10, how committed are you to change? (10 being most committed)
Do you feel there might be any resistance within you to change?
Do you have any concerns about hypnosis?
New behaviors/thoughts you wish to be suggested under hypnosis:
Describe any current conditions in your life that are negatively affecting you
List any fears or phobias
What is your most relaxing color?
What is a peaceful and calming place for you?
How did you hear about my services?
Check and briefly describe any of the following that you have used before
Hypnotherapy
Self-Hypnosis
Traditional Mental Health Therapy
Meditation, Yoga, or Breathwork
Acupuncture
Somatic Work
Other Alternative or Traditional Healing Methods
Briefly describe any of the above that you have used
What is your learning style?
Client Acknowledgment and Signature
Client acknowledges all information is complete and accurate to the best of their ability. Client acknowledges, understands, and agrees that this session is not a medical or psychological exam or diagnosis, and that hypnosis is not a substitute for medical or psychological treatment. All information is and remains confidential.
Print Name
Signature
Date

MonthDayYear
Date
Should be Empty:

Hypnosis Intake Form

Client Information

Hypnotherapy Intake

Check and briefly describe any of the following that you have used before

Client Acknowledgment and Signature