Intake Form

Client Intake Form

Confidentiality: Your information is kept confidential except where required by law.
Hypnotherapy Disclaimer: Hypnotherapy is not a substitute for medical or psychological diagnosis and treatment. Please consult your healthcare provider for concerns outside the scope of hypnotherapy.

First Name (required)

Last Name (required)

Email Address (required)

Phone Number (required)

Date of Birth (required)

Pronouns

He/HimShe/HerThey/ThemOtherPrefer not to say

Street Address

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

SpouseParentSiblingFriendOther

Session Information

What are your primary goals for hypnotherapy? (required)

Are there any specific concerns or issues you’d like to address?

Have you tried hypnotherapy before?

YesNo

If yes, please describe your experience:

Medical & Mental Health History

Do you have any current medical conditions we should be aware of?

Are you currently taking any medications?

Have you been diagnosed with any mental health conditions?

Are you currently working with a therapist or counselor?

YesNo

Additional Information

How did you hear about us?

Google SearchSocial MediaFriend/Family ReferralProfessional ReferralAdvertisementOther

If referred by someone, please provide their name:

Is there anything else you’d like us to know?

Consent & Agreement

I understand that hypnotherapy is not a substitute for medical or psychological treatment, and I have consulted or will consult my healthcare provider as needed.

I consent to participating in hypnotherapy sessions and understand I can withdraw consent at any time.

I acknowledge that my information will be kept confidential except where required by law.