Hypnotherapy Intake Form

Mind Performance Coaching and Clinical Hypnotherapy Client Form

First Name

Last Name

Address

Mobile Number

Are you currently using any prescription drugs for mental health? If so, please state the drug and it's purpose e.g. anti depressant, anti psychotic etc.

Have you ever been treated for epilepsy, heart disorder, diabetes, schizophrenia/bipolar, digestive problems? Please state.

Have you been hypnotised before? If yes, what was your experience?

What do you most want to accomplish through the use of hypnotherapy and mind coaching?

Have you previously attempted to resolve this problem? If so, what have you done and what have been the results.

Why is it most important for you to resolve this challenge and move forward?

Have you ever been treated for emotional problems? If yes, please outline.

Do you have any fears or phobias? E.g. spiders, flying, staircases, elevators, highway driving?

In submitting this form I am stating that I am willing to be guided through relaxation, visual imagery, hypnotic techniques, creative visualisation, stress relaxation and time line therapy for the purposes of self improvement,

I understand that the hypnotherapy and coaching techniques are not a substitute for normal medical and professional care and I agree to discuss this therapy with my doctor in advance if necessary.

I have read and understood the foregoing and answered all questions to my satisfaction. In consideration, I hereby waive the right to all and any claim against the practitioner for any injury or adverse change in my state of health arising directly or indirectly from my participation in this process.

SUBMIT