Hypnosis Intake Form

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Please complete this form knowing all information is confidential

First Name and Middle Initial *

Last Name *

Street Address

City, State, and Zip

Phone Number *

Email Address *

Name I like to be called

Occupation

Have you ever been treated for an emotional problem? If you have please explain..

What do you want to accomplish through the use of hypnosis? *

Any previous efforts to solve this problem? What were the results?

How did you hear about us?

Do you have any fears or phobias?

I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or old illness.

Signature (type full name) *

Date *

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