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Hypnotherapy

Intake Forms

Please fill out the following form in order to participate in any session utilizing Hypnotherapy as a potential modality.

Birthday
Month
Day
Year

If you are under 18 years of age, a parent will need to complete this form on your behalf.

This is helpful context during hypnosis sessions when clients identify an individual by name whom the therapist does not know.

Do you have children?
Yes
No

This is helpful context during hypnosis sessions when clients identify an individual by name whom the therapist does not know.

Do you wear contact lenses?
Yes
No

During hypnosis, your eyes will be closed for 45+ minutes, which may cause irritation if wearing contacts.

Do you have any hearing problems?
Yes
No

If you normally wear hearing aids, please use it as normal. During the hypnosis process, the practitioner will typically lower the volume of his/her voice to enhance trance.

Are you currently under the care of a physician?
Yes
No
Are you currently taking any medications (prescription or otherwise)?
Yes
No

Some medications are contra-indicated for use with hypnosis.

Are you currently under the care of a psychologist, psychiatrist, or mental health counselor?
Yes
No

Some diagnoses are contra-indicated for use with hypnosis.

Can you visualize an image or scene if it is described to you?
Yes
No

This is not prohibitive of a fulfilling hypnosis session, this just informs which sense(s) may be strongest for you during your session.

Have you been diagnosed with any of the following?
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Have you ever undergone hypnosis before?
Yes
No
Do you have any fears or phobias?
Yes
No

Frequently during hypnosis, your practitioner will use metaphors or symbols to help you progress. If you have any common phobias (i.e., small spaces, stairs, flowing water, etc), the use of these metaphors may be distressing for you.

Do you have a spiritual connection?
Yes
No

Frequently during hypnosis, clients will use spiritual terminology. It is helpful to know ahead of time how you view spirituality so your practitioner can use terms which are most comfortable for you.

Do you associate any of these emotions with your issue?

CONFIDENTIALITY: All sessions are confidential. We will not release any information to anyone without written authorization from you, except as provided by law

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