Hypnotherapy Intake Form (Under 18)

Name *

First

Last

Email *

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 Up

Please provide details of all medical practitioners who you are currently in the care of.

Symptoms & Treatment

If 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: *

If not listed above, please add anything else that concerns you.

Have you ever had hypnosis before?

Never
Once
Several times

If yes to the above, what did you have hypnosis for?

How effective was it in resolving your issues?

Highly effective
Effective
Ineffective