Forms

Quit Smoking Weight Loss Stress Management Overcome fears (please specify in 'other') Test Taking Medical Condition (please specify in 'other') Pain Management Sexual Difficulties Other (please specify)

What is your prior experience with hypnosis?

None Have been hypnotized at a stage show Have been hypnotized one on one Have listened to hypnosis tapes or CD's Have read books on hypnosis Have friends/family who have been hypnotized

What are your beliefs about hypnosis?

What are your three biggest personal strengths?

HEALTH: List all medical & mental health conditions for which you are currently being treated.

Diagnosis, Treating Physician, Medications *

List any other health concerns, fears, or issues *

List any other medications *

Do you smoke cigarettes? *

Never have Former smoker - if so, when did you quit? (please specify in 'other') Yes. I am a light smoker - if so, how many cigarettes per day? (please specify in 'other') Yes. I am a heavy smoker - if so, how many cigarettes per day? (please specify in 'other')

Other: *

Your age when you started smoking? *

Do you have sleep difficulties? *

In my personal relationships, I am: *

Unsatisfied Sometimes satisfied Most satisfied I am very happy with my relationships with others

What do you do to handle tension and stress? *

What do you do for fun? *

What are your hobbies? *

What do you want to accomplish with hypnosis? *

What is the most peaceful, relaxing place you can think of? *

Please check all that apply:

How will you be paying today? *

Cash Credit Card (Mastercard or Visa) Check

When you have benefitted from my Integrative Hypnosis would you be willing to email me a short testimonial? *

Yes No

When you have benefitted from my Integrative Hypnosis would you be willing to review my practice on a review site such as Google, Yelp, City Search, Angie's List? *

Yes No

INTAKE FORM

What do you want to accomplish with integrative hypnosis today?

What is your prior experience with hypnosis?

What are your beliefs about hypnosis?

What are your three biggest personal strengths?

HEALTH: List all medical & mental health conditions for which you are currently being treated.

Please check all that apply:

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