Hypnosis Intake Form
The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and as accurately as you can, you will assist me in maximizing your time and saving you money.
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Marital Status
Married
Re-married
Engaged
Separated
Divorced
Widowed
Single
Other
Prior experience with hypnotherapy?
Yes
No
What do you hope to achieve with hypnotherapy?
Give a brief account of the history and development of your complaints.
Do you have any fears? Please explain them in a detailed way.
Current health status
List illnesses and injuries.
List any medications you are taking.
How are your sleeping patterns?
Height
Weight
Relationship with father
Relationship with mother
Number and Gender of Siblings
Relationship with brother’s/sister’s
List children and ages with a short personality description of each.
Check areas where problems exist.
Children
Friends
Sex
Affairs
Communication
Work
Finances
Substance abuse
Recreation/leisure
Religious differences
Arguments
Verbal abuse
In-laws
Physical abuse
Other
What is your job?
What is your job?
Is there any other information/concerns you would like me to know?
Submit
Should be Empty: