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CLIENT INTAKE FORM

Please complete this form to help me understand you and how I can best support you.

1. PERSONAL INFORMATION
2. EMERGENCY CONTACT
3. HOW DID YOU HEAR ABOUT LIFE HYPNOTHERAPY?
4. PROFESSIONAL & MEDICAL INFORMATION
Professional History
Have you previously worked with a therapist, counselor, or psychologist?
Have you previously worked with a hypnotherapist?
If yes, was the experience helpful?
Medical Information
Do you currently have a mental health diagnosis?
Health History
Do any of the following apply to you? (Check all that apply)
5. REASON FOR SEEKING SERVICES
6. READINESS FOR CHANGE
On a scale of 1–10, how motivated are you to create this change at this time? *
Not Motivated Highly Motivated
Have you previously attempted to make this change?
7. CURRENT CHALLENGES
Please select any areas you would like support with. (Check all that apply)
8. CURRENT WELLBEING
How would you rate your current stress level?
How would you rate your sleep quality?
How would you describe your energy level?
9. ADDITIONAL INFORMATION
Is there anything you would prefer not to discuss during your first session?
10. CLIENT ACKNOWLEDGMENT & SIGNATURE
Signature * Sign above
Date *
Your information is secure and confidential.

Practical guidance.
Lasting Transformations.
Meaningful Change.

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