CLIENT INTAKE & CONFIDENTIAL HISTORY
We ask that all clients provide a full and complete confidential history so that we may best assist you. Some medical-related questions are pertinent and important as we do not want to interfere with any ongoing treatment or care. If you have questions regarding this form please contact me at firstname.lastname@example.org. Thank you.
If yes, what was the reason and how did it go for you?
If yes, do you believe you were hypnotized and why?
What is your main purpose for purchasing this program? What issue are you most looking to resolve/eliminate at this time? *
Have you attempted to address this issue before? What did or didn’t work?
If you answered "yes" to either of the questions above, please explain your reason for care.
If yes, what are you taking and what is the purpose of this medication?
If yes, what are you taking and why?
Emergency Contact Name, Info & Relationship *
Do you have any questions about hypnosis or coaching?
All appointment changes or cancelations require 48 hours of advanced notice prior to your scheduled appointment.