Hypnotherapy Intake FormPlease enable JavaScript in your browser to complete this form.Personal InformationName *FirstLastEmail *Cell Phone *Home PhoneWork PhoneIs it ok to contact you at home? *YesNoAddress *Address Line 1CityCaliforniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Occupation/Current Work *Education *Other TrainingSpecial AptitudesPlease note any medication or other preparations (e.g., vitamins) and daily dosage.What specific problem or situation brings you in? (Summarize briefly)Here is a list of life-areas and common difficulties which often lead people to seek professional assistance. Please check those you feel may also apply to you. *Alcohol UsageArtist's BlockAthletic PerformanceBody ContouringCreativityDepressionDrug UsageEating ProblemsEmotional UpsetEveryday FearsGuilt FeelingsHabit ControlInsomniaLying/CheatingMemory RecallMoney WorriesMotion SicknessPhobic ReactionsResidual PainRelationshipsRelaxationSchool ProblemsSelf-MotivationSexualityShynessStress/TensionSurgery PreparationWeight ControlWork ProblemsOtherIf you answered "Other" in the previous question, please explain.Preliminary Questions1) How did you happen to hear about me? *2) Have you ever been in counseling or psychotherapy? If so, how long and with what results? *3) What would you say is your main concern at this time? *4) What would you be willing to let go of or give up to handle this concern, problem or situation? *5) What would you "not" be willing to let go of or give up to handle this concern, problem or situation? *6) Have you ever been in hypnosis? If so, under what conditions? *7) Have you ever seen anyone hypnotized? How did you feel about that and how did others around you respond? *8) Describe (2) of your favorite scenes or places which symbolize to you good feeling such as peace, contentment or relaxation. Focus on sights, sounds, smells, temperature, movements, tastes, feelings on your skin (wind, clothing, etc.) and any other sensations or emotions each scene evokes in you. *Informed ConsentHypnotherapy is a highly effective healing modality for most people. For some, it may be intense, and inner material may come up both in and after sessions. This is actually a healing experience when properly understood. The best action to take is to call your hypnotherapist and get assistance. Most people find they have positive experiences. "I understand this, and I am willing to give it my best. I take responsibility for myself." *Clear SignatureSignatureMessageSubmit
