Hypnosis with Jerri - Intake Questionnaire
Note: All information will be kept strictly confidential except that which I am legally obliged to report such as threat of injury to yourself or others. If you are in any way uncomfortable with any of these questions, feel free to skip them. Please be aware that the more you tell me about yourself, the more I may be of assistance to you. Feel free to use the space at the bottom to go into detail about anything you wish for me to know about you or to help you with. It is my honor to assist you.
Full Name *
Your answer
Date of Birth *
Your answer
Gender *
Address (Number, Street, Apt) *
Your answer
City, State and Zip Code *
Your answer
Phone number *
Your answer
Email *
Your answer
Preferred way of contact *
Best time to contact
Your answer
Personal Status *
Partner's Name
Your answer
Name & Ages of Children
(If you don't have children, skip this question)
Your answer
List you 3 favorite colors in order of preference *
Your answer
List you 3 favorite places in order of preference *
Your answer
On vacation, which do you prefer? *
List any fears you may have
Your answer
Do you experience any compulsive tendencies?
One word or short phrase
Your answer
List any current health problems *
Your answer
Are you being treated by a physician, psychologist or psychiatrist?
If you answered YES to the previous question, can you summarize the reason why you are being treated?
Your answer
List any medications you are currently taking
Your answer
List any herbs or vitamins you regularly ingest
Your answer
List your three (3) most important lifetime goals
Your answer
List your three (3) favorite pastime/hobbies
Your answer
What is your current occupation?
Your answer
Do you enjoy your work?
List some things that you like to do and wish you could be better at:
Your answer
If you could be, do, have, or become anything, what would you wish for?
Your answer
Why are you seeking hypnotherapy? *
Your answer
Are you currently experiencing any of the following? *
Check all that apply
Required
Do you follow any religious or meditative practices? *
If yes, describe
Your answer
List any conditions occurring in your life that you believe are negatively affecting you in any way
Your answer
Use this space to tell me specifics of your needs/concerns, if necessary
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy