Intake Form | sej-mindshift.com

Client Intake Form

01 / About you & your health

Preferred known by name

Last name

Are you currently taking prescription drugs, or have you stopped taking any in the last 12 months? If so, what are they?

Have you ever been diagnosed with any mental health issues? If yes, please include details

Are there any other health issues I should be aware of?

Are you currently in employment? If so, what is your occupation

What are your hobbies?

02 / What brings you here

What is the reason for you seeking hypnotherapy?

Is there a specific reason why this has come to a head now?

When did this issue first start, if you can remember?

Do you have any other fears or phobias, such as animals or heights?

Do you have any concerns or questions regarding hypnotherapy?

Have you had any form of treatment for this problem in the past? If so, what was the treatment, and how did it go?

03 / Your reflections & signature

During our sessions it is nice to establish a "pleasant-safe place" for you to visit in your mind, where you feel happy, safe and at peace. It should be somewhere you are alone and undisturbed. It could be a room in your home, the countryside or a beach; a place you have been before or somewhere completely from your imagination. Describe what your pleasant, safe place would look like to you.

Safe Place

Is there an event in your life that you can remember where you felt confident and happy? If not, can you imagine what this would look like if it happened in the future? How would you see yourself on your perfect day?

Event

Is there anything else you feel I should be aware of?

Client Consent Declarations

Signature

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