Transformational Hypnosis
Initial Intake Form
(All Information is Strictly Confidential)
First name:
Last name:
Today's Date:
How did you hear about us?
Friend
Relative
Website
Internet Search
Health Care Referral
Other
Religious or Spiritual beliefs?
Address:
Phone number (Cell):
Other Number:
Email:
Birthday
Month
Day
Year
Place of Birth
Occupation:
Employer:
Highest Level of Education:
Medical Doctor
Permission to contact your Doctor(s) to release information if needed?
Yes
No
Have you ever undergone hypnosis before? (If so, when, why & with whom):
MEDICAL HISTORY:
Have you been under physical or psychological treatment within the past two years?
Yes
No
If so, describe
Doctor(s) Name & Number
Have you ever received professional services for an emotional/psychological problem?
Yes
No
If so, describe
Doctor(s) Name & Number
Are you taking any prescription medications? (Attach list if needed)
Yes
No
Medication / Dosage / Reason / How long?
Medication Upload (if needed):
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Have you been treated for: (Check all that apply)
Diabetes
Epilepsy
Heart attack
Stroke
Weight
Leg/Arm problems
Vision
Stomach/IBS/UC
Respiratory problems
Headaches / Migraines
Other
Do you smoke?
Yes
No
# Per day / How many years?
Do you drink alcohol?
Yes
No
# Per week / How many years?
Nature of present problem or problems? (Reason you wish Hypnosis sessions.) List all that apply.
Your previous efforts to solve the issue? Please describe.
Are you currently undergoing medical or psychological treatment for the problem?
Yes
No
Other
Doctor(s) Name & Number
Signature below indicating all information is true and accurate.
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Date:
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Initial Intake Form