CONFIDENTIAL HYPNOSIS CLIENT QUESTIONNAIRE

Confidential Hypnotherapy Client Questionnaire

All information will be kept strictly confidential except that which I am legally obliged to report, such as a threat of injury to yourself or others. If you are uncomfortable in any way with any of these questions, feel free to skip them. Please be aware that the more you can tell me about yourself, the more I may be of assistance to you. Feel free to go into detail about any issue you wish me to know about you, or to help you with.
Name
Age
Email
example@example.com
Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Marital Status

SinglePartneredMarriedSeparatedDivorcedWidowed
Name of Spouse/Partner if applicable
Names and ages of any children
Current Occupation
Do you enjoy your work?
Have you experienced Hypnosis before?
Have you ever needed to work with mental health professionals? If yes, please provide further information.
Do you have any current health problems? If so, please provide further details of conditions and treatment
List any medications you are currently taking, the dosage and side effects for you
Please list any fears, phobias or compulsive tendencies
Please list any other conditions occurring in your life that you believe are negatively affecting you in any way, or provide details of your concerns, needs or fears
How would you like Hypnotherapy to help you?
Sometimes we have a few problems to resolve. If you could narrow it down, which one is more important to work with in our Hypnotherapy session and why?
Now, imagine yourself without this problem. How would your life be different?
Would you describe yourself as an analytical person? Yes/No
What (if anything) would you like to do better in your life?
Are you currently experiencing any of the following?

NervousnessInability to relaxSleeplessnessDepressionNail bitingNightmaresSexual DysfunctionCompulsive TendenciesTeeth GrindingPoor HealthAlcohol AbuseDrug AbuseCigarette SmokingCompulsive OvereatingSelf MutilationSerious Eating DisorderInability to focus attentionCo-DependencyMarital ProblemsRecent DivorceWar TraumaChildhood TraumaIllness or death of a loved oneLack of energyLow self esteemADD or ADHDAbusive home sitationPTSDAbusive work situationLack of successOther
Please list your two favourite places in order of preference
How do you like to relax?
What are your two most important lifetime goals?
List your favourite hobbies
What is your greatest dream for yourself?
I hereby authorise Louisa Rhodes to use Hypnosis Techniques on me for the purposes outlined in this form, and for future purposes that I may request. I understand that Hypnosis and Regression Therapy are not medical procedures and that no medical benefits are being offered to me. I understand that the success of Hypnosis and Regression Therapy depends on my ability to relax, and my desire to create change in myself. I understand that because the results of the sessions depend on my own serious participation, Louisa Rhodes cannot offer any guarantee of the success of my treatment. I am aware however, that she will do everything reasonable in her ability to ensure my success.*

I agreeI disagree
I work to international standards set through voluntary regulation in the profession itself. This is through the Earth Association of Regression Therapy and not by any country or state licensing requirements.

The way I that work will help you find your own inner resources for healing, but it will involve you needing to be prepared to go into deeper or buried memories, and it may involve emotions coming to the surface and some physical touch to support you if body memories need to be transformed.

The truth of any memories that may come to your conscious awareness during our sessions is for you to decide.

I can offer to give you my best professional service to assist you on this journey, but you are responsible for your own healing.
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Confidential Hypnotherapy Client Questionnaire