Custom Hypnosis Intake Form

Name:	Date:
Address:
Phone:	Email:
Age:	Medical History:
Current Medications:
Treated for psychological or physical issues in the past year? Describe.
Doctor's Name:	Doctor's Phone:
Are you currently receiving counseling?	Yes No
Reason for Hypnotherapy:
Any other issues you wish to address in the future?
Hobbies:	Work:
Your Age:	Your Health:
Spouse Age:	Spouse Health:
Parents Age:	Parents Health:
Sibling Age(s):	Sibling Health:
New behaviors you wish to be suggested under hypnosis:
An event in your life when you felt just terrific:
A word to describe that wonderful feeling:
Typing name here is equivalent of signature:
	Client acknowledges all information is complete and accurate to the best of their ability. Client acknowledges this session is not a medical or psychological exam or diagnosis. Hit the submit button to send your form in. After it has been submitted, you will be contacted shortly to confirm. Thank you.
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