Intake Form – Our Minds Are Amazing!

Please complete this form (All information is strictly confidential)

Name *

Phone *

Email Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Birthdate

Have you ever been treated for an emotional problem?YesNo

If Yes, please explain:

Any other issues or concerns that might be important to know?

Have you ever been hypnotized before?YesNo

If yes, please explain:

What do you want to accomplish through the use of hypnosis?

Any previous efforts to solve this problem?YesNo

If Yes, results:

Any fears or phobias?

Anything else you think I should be aware of as we proceed?

What, if any, is your "spirituality"?

I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or old illnesses. *YesNo