Hypnosis with Jerri - Intake Questionnaire

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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 *

Date of Birth *

Gender *

Male

Female

No disclosure

Address (Number, Street, Apt) *

City, State and Zip Code *

Phone number *

Email *

Preferred way of contact *

Phone

E-Mail

Mail

Other:

Best time to contact

Personal Status *

Single

Married

Divorced

Gay

Bi-Sexual

Other:

Partner's Name

Name & Ages of Children

(If you don't have children, skip this question)

List you 3 favorite colors in order of preference *

List you 3 favorite places in order of preference *

On vacation, which do you prefer? *

Relaxation

Excitement

List any fears you may have

Do you experience any compulsive tendencies?

One word or short phrase

List any current health problems *

Are you being treated by a physician, psychologist or psychiatrist?

Yes

Clear selection

If you answered YES to the previous question, can you summarize the reason why you are being treated?

List any medications you are currently taking

List any herbs or vitamins you regularly ingest

List your three (3) most important lifetime goals

List your three (3) favorite pastime/hobbies

What is your current occupation?

Do you enjoy your work?

Yes

Clear selection

List some things that you like to do and wish you could be better at:

If you could be, do, have, or become anything, what would you wish for?

Why are you seeking hypnotherapy? *

Are you currently experiencing any of the following? *

Check all that apply

Nervousness

Inability to relax

Sleeplessness

Compulsive tendencies

Nail biting

Teeth grinding

Nightmares

Cigarette smoking

Alcohol abuse

Drug abuse

Compulsive overeating

Codependency

Inability to focus attention

Poor memory

Marital problems

Recent divorce

War trauma

Fear of heights

Death of a loved one

Childhood trauma

Lack of energy

Poor self-esteem

Abusive home situation

Abusive work situation

Current illness/poor health

Lack of success

Other:

Required

Do you follow any religious or meditative practices? *

Yes

If yes, describe

List any conditions occurring in your life that you believe are negatively affecting you in any way

Use this space to tell me specifics of your needs/concerns, if necessary

Submit

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