Hypnotherapy Intake Form Please fill out our hypnotherapy intake form. After completion of the form, you will be redirected to the booking page. Health HistoryMartial Status *SinglePartneredMarriedSeparatedDivorcedWidowedGender *MaleFemaleBest Way To Contact You? *PhoneEmailWho referred you/how did you hear about me? *Have you ever been hypnotized? *YesNoPersonal Health HistoryAny problems that other health care practitioners (doctors, healers, etc.) have diagnosed? In addition, Are you under a doctor’s care, and if so, for what reason?Have you ever had any other serious accidents, injuries or illnesses? Please include surgeries or hospitalizationsWhat other traumas are you aware of experiencing in your lifetime?Do you have any specific fears or phobias that you are aware of? (e.g. flying, heights, water, etc.) Please include any recurring bad dreams.List any prescribed drugs, over-the-counter drugs, vitamins, remedies or inhalers that you are using.Are you concerned about the amount you drink? *YesNoAre you concerned about drug use, pharmaceutical or street? *YesNoWould you like to discuss alcohol or drug use during your treatment? *YesNoDo you use tobacco? *YesNoWould you like to discuss tobacco use during your treatment? *YesNoPhysical and/or mental abuse has become a major public health issue. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your practitioner? *YesNoAre there any other personal safety concerns you wish to highlight? If so, please describe below *YesNoGeneral Wellness Assisting me to understand your current emotional and mental state can help considerably with your treatment. Please consider answering the following questions: Is stress a major problem for you? *YesNoDo you feel depressed? *YesNoDo you have anxiety or panic when stressed? *YesNoDo you have problems with eating or your appetite? *YesNoDo you have trouble sleeping? *YesNoHave you ever been to a counselor? If yes, please describe. *YesNoWas the counseling of assistance to you? *YesNoAre you pregnant? *YesNoWould you like information about Hypnosis for Birth? *YesNoCHECK IF YOU HAVE, OR HAVE HAD, ANY SYMPTOMS IN THE FOLLOWING AREAS TO A SIGNIFICANT DEGREE AND BRIEFLY EXPLAIN.SkinHead/NeckEarsNoseThroatLungsChest/HeartBackIntestinal/IBSBladderBowelCirculationRecent changes inWeightEnergy levelAbility to sleepOther pain/discomfortSuggestibility QuestionnaireHave you ever walked in your sleep during your adult life? *YesNoAs a teenager, did you feel comfortable expressing your feelings to one or both of your Maternal and Paternal figures? *YesNoDo you have a tendency to look directly into people's eyes and/or move close to them when discussing an interesting subject? *YesNoDo you feel that most people you meet for the first time are uncritical of your appearance? *YesNoIn a group situation with people you have just met, would you feel comfortable drawing attention to yourself by initiating a conversation? *YesNoDo you feel comfortable holding hands or hugging someone you are in a relationship with while other people are present? *YesNoWhen someone talks about feeling warm physically, do you begin to feel warm also? *YesNoDo you occasionally have a tendency to tune out when someone is talking to you, and at times not even hear what the other person is saying, because you are anxious to come up with your side of it? *YesNoDo you feel that you learn and comprehend better by seeing and/or reading than by hearing? *YesNoIn a new class or lecture situation, do you usually feel comfortable asking questions in front of the group? *YesNoWhen expressing your ideas, do you find it important to relate all the details leading up to the subject so the other person can understand it completely? *YesNoDo you enjoy relating to children? *YesNoDo you find it easy to be at ease and comfortable with your body movements, even when faced with unfamiliar people & circumstances? *YesNoDo you prefer reading fiction rather than non-fiction? *YesNoIf you were to imagine sucking on a sour, juicy, yellow lemon, would your mouth water? *YesNoIf you feel that you deserve to be complemented for something well done, do you feel comfortable if the compliment is given to you in front of other people? *YesNoDo you feel that you are a good conversationalist? *YesNoDo you feel comfortable when complimentary attention is drawn to your physical body or appearance? *YesNoSuggestibility Questionnaire Part 2Have you ever awakened in the middle of the night and felt you could not move your body and/or could not talk? *YesNoAs a child, did you feel that you were more affected by the tone of voice of your Maternal and Paternal figures than by what they actually said? *YesNoIf someone you are associated with talks about a fear that you too have experienced, do you have a tendency to have an apprehensive or fearful feeling also? *YesNoIf you are involved in an argument with someone, after the argument is over do you have a tendency to dwell on what you could or should have said? *YesNoDo you have a tendency to tune out occasionally when someone is talking to you, perhaps not even hear what was said, because your mind has drifted to something totally unrelated? *YesNoDo you sometimes desire to be complemented for a job well done, but feel embarrassed or uncomfortable when complemented? *YesNoDo you often have a fear or dread of not being able to carry on a conversation with someone you have just met? *YesNoDo you feel self-conscious when attention is drawn to your physical body or appearance? *YesNoIf you have your choice, would you rather avoid being around children most of the time? *YesNoDo you feel that you are not relaxed or loose in body movements, especially when faced with unfamiliar people or circumstances? *YesNoDo you prefer reading non-fiction rather than fiction? *YesNoIf someone describes a very bitter taste, do you have difficulty experiencing the physical feeling of it? *YesNoDo you tend to feel awkward or self-conscious initiating touch (holding hands, kissing, etc...) with someone you are in a relationship with while other people are present? *YesNoIn a new class or lecture situation, do you usually feel uncomfortable asking questions in front of the group even though you may desire further explanation? *YesNoDo you feel uneasy if someone you have just met looks you directly in the eyes when talking to you, especially if the conversation is about you? *YesNoIn a group situation with people you have just met, would you feel uncomfortable drawing attention to yourself by initiating a conversation? *YesNoIf you are in a relationship or are very close to someone, do you find it difficult or embarrassing to verbalize your love for him or her? *YesNoThank you for sharing this information. This information will assist the practitioner to tailor your treatment appropriately.By submitting this health record, you agree that you have provided this information voluntarily and are undertakinghypnotherapy with this office voluntarily. You agree to release this practitioner from all liability and will not hold thepractitioner responsible in any way for outcomes resulting from methods, instructions and programs used in the courseof your treatment.24 hour notice of cancellation is required, otherwise a full rate for the appointment will be charged. Send Message Get in touch with Rickie Start Your Spiritual Journey Today 0 / 300 Send Message
