Hypnotherapy Intake Form

Required Field

Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor

Doctor's Name

Doctor's Phone

Doctor's Address

Goals and Previous Experience

What would you like to accomplish through the use of Hypnosis? Please elaborate as much as you like, the more detail you provide, the more information we have to work with!

Have you ever been Hypnotized before? Please explain.

Characters: 0/255

Any previous efforts to solve this problem? Please Explain

Characters: 0/255

Do you have any fears or true phobias?

Characters: 0/255

Where did you hear about me?

Characters: 0/255

Conditions

Have you been treated for an emotional problem? If yes please explain

Have you ever been treated for Diabetes?

Characters: 0/255

Have you ever been treated for Epilepsy?

Characters: 0/255

Have you ever been treated for a Heart Disorder?

Characters: 0/255

Have you ever been treated for Digestive Problems?

Characters: 0/255

Review & Agree

Willingness to be Hypnotized (Review Required)

You need to review and accept this before submitting

Signature