Intake & Consultation Form
Hypnotherapy and Past Life Regression
Full Name
*
First Name
Last Name
Preferred Name
Date of birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Post Code
Phone Number
*
 -
Area Code
Phone Number
E-mail
example@example.com
Relationship Status
*
Occupation
*
Emergency contact name and phone number
*
Doctors details - name, address and phone number
*
Date of last check up
*
Medications taken - please list below
*
Hypnotherapy cannot be practiced on anyone who has epilepsy or diagnosed psychiatric condition.
By filling in this form, you agree that you have neither of these conditions.
I have been hypnotised before
*
Yes
No
Can't remember
Please provide me with a bit more information if you HAVE been hypnotised before.
From the list below - tick your areas of concern
Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive behaviour
From the list below - tick your areas of concern
Anxiety
Stress
Fears
Phobias
Panic Attacks
Guilt
Relaxation
From the list below - tick your areas of concern
Eating problems
Food/Diet
Weight Problems
Anorexia
Bulimia
Exercise
From the list below - tick your areas of concern
Depression
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
From the list below - tick your areas of concern
Career Issues
Interview Skills
Nerves
Public Speaking
Concentration
Exams
Memory
Driving Skills
From the list below - tick your areas of concern
Sexual Problems
Fertility
IVF
Conception
Pregnancy
Birth
From the list below - tick your areas of concern
Pain Control
Hearing
Sight/Vision
Mobility
Skin Problems
Hair Growth
From the list below - tick your areas of concern
Relationships
Childhood Problems
Sleep Problems
Is there anything else you would like to tell me?
How did you hear about this?
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