Hypnosis Intake Form Hypnosis Intake Form "*" indicates required fields Client Name :*Date :* MM slash DD slash YYYY Email :* Phone :*Address :Previous Hypnosis : Yes No Date(s) : MM slash DD slash YYYY Purpose :Results :Marriage Status : Married Single Divorced Widowed Diagnoses : Bipolar Disorder Schizophrenia Epilepsy PTSD Depression OCD Current Medications :Current Physician :Phone :Permission to contact :Hypnosis Target Smoking Sexual Issues Relationships Sleep Anxiety/Fear Pain Forgiveness Public Speaking Weight Loss Pregnancy/Childbirth Stress Motivation / achieve a goal Menopause Phobias Trauma Abuse Anger Studying Mental Health Self Image Notes/Comments:*For legal reasons, we must state that the ideal results described on this site, including testimonials, represent the outcome of an ideal client. Your results might be different, and will depend on your hpnotic suggestibility, motivation to change, past history, and many other factors that are not in our control. In addition, our owkr as hypnotherapists is not medical care, psychotherapy or psychological advice.WAIVER :A clearance from your family doctor/psychiatrist may be needed depending on your condition.CAPTCHANameThis field is for validation purposes and should be left unchanged.
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