General Intake Form

General Client Intake Form

Session Date / Time

First Name

Last Name

Age

Birthday

Place of Birth

Gender

Marital Status:

Address

City

State

Country

Mobile Phone

Occupation

Religion

No. of Children

Children Ages/Gender

What hobbies or enjoyable pastimes do you have?

Doctor

Address

Phone

Current Medications

Do you currently take nutritional supplements? If so, please list

Are you interested in health, vitality & wellbeing? 1 (not at all) 10 (very much) please indicate

Do you exercise? If so, what type and how many times a week?

Do you smoke? If so, how many per day

Do you suffer with any of the following conditions? If so, please place X next to appropriate ones.

Conditions details/explanations

Have you ever been diagnosed with Dissociative Identity Disorder, Psychosis, Schizophrenia, Epilepsy?

Please list other therapies you have experienced (i.e. alternative healing, massage chiropractor, etc)

Have you experienced hypnosis?

Yes

Performed by

Purpose

Do you take recreational drugs? If so, what & how often.

Do you have any dietary/eating problems?

Do you drink alcohol? If so, what and how much/how often?

Have you ever done yoga/meditation?

Yes

Have you ever been in counselling?

Yes

List all the reasons that you are undertaking this program in order of priority

What else have you done to deal with this issue?

What should I know about you to be able to help you succeed most powerfully?

What strengths do you have?

What weaknesses do you have that may hinder you from attaining your goals?

Describe your most relaxing outdoor place

What are your expectations of this program?

What are your expectations from your therapist?

What else should I know about you?

What is ONE thing you could do (that you’re not doing now) that if you did on a regular basis would make a tremendous positive difference to your life?

Who referred you, or how did you hear about this service?

To the best of my knowledge this information is true and correct. I understand that all information I have provided will be held in the strictest confidence. I request hypnotherapy if deemed appropriate.