Client History--Pure Space Hypnosis
This form is to be completed at the initial sessions
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Email *
Name *
Address *
Cell phone *
Email address *
Date of Birth *
MM
/
DD
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YYYY
Gender
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Martial Status
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How did you hear about us? *
Who referred you?
Primary Care Physician--Name & Address
Have you been under medical care in the last year?  If so, please give the reason. *
Have you been treated for?
What are your current medications? *
Have you ever been treated for an emotional problem? If yes, explain. If you are receiving counseling currently,  please note that as well. *
What is your experience with hypnosis?  Has anyone every tried to hypnotize you? Do you believe you were hypnotized?
Why are you coming in for hypnosis? *
What have you tried to solve this problem? *
Are you currently undergoing any medical or psychological treatments for the above problem? *
If you are undergoing treatment, who is your doctor or care provider?
Do you have any questions about hypnosis? *
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