Hypnosis Intake Form
Please complete this form knowing all information is confidential

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First Name and Middle Initial *
Last Name *
Street Address
City, State, and Zip
Phone Number *
Email Address *
Name I like to be called
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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