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Pain Management Intake Form
Please fill out all of the questions below before to your first session. This is confidential.
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Name
*
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Marital Status
Single
Common Law/Married/Partnered
Separated
Divorced
Widowed
Other:
Clear selection
Birthday
MM
/
DD
/
YYYY
Sex
Male
Female
Non-Binary
Prefer Not To Say
Other:
Clear selection
Education
High School
College
University
Masters Degree
PHD
Clear selection
If College or higher, Please provide your Degree & Major
Your answer
Occupation
Your answer
Favourite Hobbies
Your answer
Do you enjoy your work?
Yes
No
Clear selection
Are you currently under the care of a physician?
*
Yes
No
Other:
If yes, please include the name of your doctors/specialists (your medical practitioner will not be contacted)
Your answer
Are you currently receiving conventional or alternative treatments?
Yes
No
Clear selection
If yes, what type? (Homeopathy, medications, acupuncture, etc.)
Your answer
Are you currently receiving any other types of support? (Therapist, Life Coach, Spiritual Healer, etc.)
Yes
No
Clear selection
If yes, please elaborate
Your answer
Do you have light sensitive epilepsy?
*
Yes
No
How often do you exercise?
I don't exercise
1x per week
2-3x per week
4-5x per week
Daily
Multiple times a day
Clear selection
What do you expect from hypnosis?
Your answer
Have you ever been hypnotized before? Results?
Your answer
How did you hear about us?
Google
Social Media
Referral
Newspaper
Radio/TV
Clear selection
If you were referred by a former client, please let us know who so we can send a thank you note.
Your answer
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