Hypnotherapy Intake Form (Under 18) Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Date of Brith *Contact Number *Briefly describe the ONE main problem/issue that has prompted you to consider hypnotherapy. *How is this problem/issue affecting you - how is it showing up emotionally or physically?What is your desired outcome from hypnotherapy? *Describe life without this problem/issue (how do you want it to look and feel?)Commitment to Change *On a scale of 1 - 10, how committed are you to being free of this issue/changing your circumstances?Doctor(s) Name, Address & Date of Last Check UpPlease provide details of all medical practitioners who you are currently in the care of.Symptoms & TreatmentIf your issue is a physical illness or problem, please explain and list your symptoms/your doctor or health care providers recommendations/anything else that might be useful for me to know.Please list any medications and supplements being taken *Please select the issues that concern you from the list below: *ConcentrationMotivationMemoryGoal AttainmentPublic SpeakingExam PreparationDepression AnxietyPanic AttacksConfidenceSelf-EsteemRelationshipsCompulsive BehaviourGuiltFearsPhobiasRelaxationStressNervesAngerSkin ProblemsSleep ProblemsPain ManagementWeight ManagementDisordered EatingIf not listed above, please add anything else that concerns you.Have you ever had hypnosis before?NeverOnceSeveral timesIf yes to the above, what did you have hypnosis for?How effective was it in resolving your issues?Highly effectiveEffectiveIneffectiveNameSubmit