Ernest Frost Hypnotherapy New Client Intake
Standard online intake form for new clients. Please complete all requested details and answer the questions as fully as possible.
Client Contact & Basic Details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth / Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address / Suburb / Country
*
Occupation / Current Work
Relationship Status
Relationship Status
*
Single
Relationship
Married
Separated / Divorced
Other
Relationship Status - Other
Presenting Concerns
Main reasons you are coming to see me
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How long has this been affecting you?
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If our work together was successful, what would be different in your life?
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What would you like to feel instead of how you currently feel?
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What behaviors would you like to stop doing or do less of?
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What behaviors would you like to do more of?
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Current Challenges & Patterns
Current Challenges
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Anxiety / overthinking
Stress / overwhelm
Low confidence
Relationship challenges
Childhood experiences affecting me
Sleep difficulties
Panic attacks
Mood swings
Grief or loss
Procrastination
People-pleasing
Self-criticism
Trauma-related responses
Other
Current Challenges - Other
Thoughts or beliefs that seem to hold you back
Patterns that keep repeating in your life that you would like to change
Emotional History & Childhood Experiences
Emotions you experience most often
*
Fear
Sadness
Anger
Guilt
Shame
Anxiety
Loneliness
Helplessness
Other
Emotions - Other
Important childhood experiences or life events that shaped who you became
Times in life where you felt not loved enough
Times in life where you felt not safe
Times in life where you felt not seen or valued
Strengths, Meaning & Preferences
Before life became stressful, what did you naturally love doing?
Qualities people who know you well appreciate about you
Achievements or moments in your life you are proud of
What gives your life meaning
Where do you feel most calm or peaceful
Favourite places you have travelled or special memories
Favourite type of nature
Ocean
Forest
Mountains
Rivers
Gardens
Lakes
Countryside
Desert
Other
Favourite type of nature - Other
Animals you love or feel connected to
Pets (past and present)
Music you enjoy
Hobbies, interests or passions
Sports, activities or things you enjoy(ed)
Favourite books, movies, stories or characters
A place (real or imaginary) where you would feel completely safe and relaxed
Goals & Additional Notes
Imagine yourself 12 months from now — “I am someone who…”
What do you want more of in your life?
What are you ready to let go of?
Anything else I should know that may help our work together?
Configurable list
*
Best Time(s) to Contact You
Have you previously tried hypnotherapy or similar therapies?
Yes
No
Any current medications or supplements?
Do you have any medical or mental health diagnoses we should be aware of?
What would make you feel safe and comfortable during sessions?
Submit
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