INTAKE

Intake Form

Patient Name *

First

Last

Phone Number *

E-mail Address *

Address *

City / State / Zip *

Patient Age *

How Did You Find Us? *

Referral from health provider, Psychology Today, Yelp, Google, etc.

Occupation *

Please list any questions, concerns or fears you have about hypnosis. *

List all medical and mental health conditions for which you are currently being treated. *

What do you want to change, create, or improve through hypnosis? *

How long have you been having difficulty in this area? *

What was happening the first time that you became aware of this issue? When do you think this started and why? *

Is another person involved in causing the issue? If so, how are they involved? *

Has it caused any compulsive tendencies, seemingly out-of-control behaviors or physical issues? (Example-can’t sleep, staying at home, etc.) *

Describe in detail how changing this would make you feel. *

Where is a place where you feel most relaxed? (Example-forest, beach, when it's raining, etc.) *

Please Read and Check *

I agree to willingly participate in therapy to the best of my ability, and understand that the therapist will keep me from harm and wants to create the best outcome for me.