Name
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First Name
Last Name
Preferred Name
First Name
Last Name
Date of Birth
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MM
DD
YYYY
Phone
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(###)
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Email
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Relationshp Status
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Occupation:
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Doctor's Name:
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Date of last check up:
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MM
DD
YYYY
Current Medications:
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Health Issues: Past and Current:
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Who do you live with? Spouse, children, pets
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What is the main reason for the session? What is the main issue you want to overcome?
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How does this issue affect your daily life? What are the Symptoms/Triggers/ Habits as a result of this issue?
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What was your childhood like? Parents, brothers, sisters? How many siblings? What was your relationship like with them?
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What bothers you the most about this main issue?
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What will your life look like without the issue?
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How will you know when the issue is gone?
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What have you done in the past to attempt resolving this issue?
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On a scale from 1-10, how committed are you to changing this issue for yourself? (10 is 100% committed)
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On a scale from 1-10, What is your belief that the outcome you desire is available to you?
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Please check all areas of concern, and add any areas of concern not listed under "Other".
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If "Other" please explain.
Have you ever been hypnotized? If so, when and what for?
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What will your life be like without this issue? How would you FEEL? What would you do? Not do? How would this affect others in your life? How would your life be different? Take time to answer.
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Describe how YOU want your life to be. Take a moment to close your eyes, relax and imagine your life just as you want it to be. I want you to allow yourself to DREAM and envision your future without this issue, include all the frills, and positive details in your description....DREAM BIG! Please write in the present tense, in second person form, as if you are talking to yourself in the mirror. For Example: ( You are strutting into your bosses office. You are full of unwavering confidence as you hand in your resignation).
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I confirm that I have completed the client intake form to the best of my knowledge and that I understand that I take full responsibility for the outcome of the session and my own physical and emotional health and well being. Furthermore, I understand that the healing process requires my full participation, including listening to the hypnotic recording everyday for at least 21 days and that it is my choice to follow the instructions or not. * By typing your name, you are authorizing consent.*
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