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Client Questionnaire

Client QuestionnaireSHAdmin2020-04-08T23:53:46+00:00

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GENERAL CLIENT INFORMATION
Items with an * are required.
Name*
Age
Date of Birth

DD
MM
YYYY
Email*
Primary Phone*
Secondary Phone
Address
Street Address Address Line 2 City State ZIP Code
Occupation
Employer
Marital Status
Significant Other's Name
How Long
How Many Children
Names
Ages

How did you hear about us?
What is the specific problem or situation we can help you with? (brief summary)
Note any conditions requiring your hospitalization or outpatient treatment over the last three years. Include dates.
Currently in treatment for:
List medications:
Have you ever been in counseling or psychotherapy? If so, how long and with what results?

Have you ever been hypnotized?
- Yes
- No
Was it successful?
- Yes
- No
I, the undersigned, having requested a consultation for hypnotherapy, understand that hypnotherapy is a conditioning process, whereby an individual is taught to use their own abilities, for their own lasting results. I understand that personal results vary. Further, I am aware that hypnotherapy is non-medical, and agree to consult my personal doctor for medical advice and/or treatment.

I realize that missed appointments, without 24 hours notice, will be fully chargeable to me at regular rates.

I understand that I am responsible for the results of my hypnotherapy, and that all payments, for past, current, or future sessions, are non-refundable.

I also understand that all information is strictly confidential.
Signature*
Date*
Date Format: MM slash DD slash YYYY

UNWANTED EMOTIONS
Unwanted Emotions
- Depression
- Too emotional
- Fear mental state getting worse
- Post traumatic stress
- Anxiety
- Anger
- Quick to anger
- Verbally abusive
- Sadness
- Feel sad frequently
- Frequent crying
- Guilt
- Shy
- Too sensative
- Too nervous
- Easily influenced
- Don't like people
- Don't trust others
- Fear of dying
- Fear of flying
- Other Fear/s
- Phobias
List Phobia/s
List Other Fear/s
DO YOU HAVE A HISTORY OF:
Do you hav a history of:
- Physical abuse
- Family abuse
- Sexual abuse
- Childhood abuse
- Suicide attempts
HABITS
Habits
- Smoking
- Drug Problem
- Alcohol Problems
- OCD Behavior
- Other bad habits
How many packs do you smoke per day?
Which drugs so you abuse?
How much of what type of alcohol do you drink?
What OCD Behavior/s Do You Experience
List Other Bad Habits

PHYSICAL PAIN
Physical Pain
- Acute Pain
- Chronic Pain
- Pending Surgery
- Cancer
- Lupus
- Fibromyalgia
PERSONAL ISSUES
Personal
- Cannot express emotions
- Do not communicate well
- Speaking problems
- Fear responsibility
- Get sick a lot
- Aging faster than I prefer
- Lack of energy
- Cannot get up mornings
- Lack imagination
- Bad dreams
- Feel awkward
- Blood pressure
- Highs and lows
- Menopause difficulties
- Allergies
- Symptoms
- No time to relax
- Need more fun
- Grieving over someone
Who are you grieving over and when did you experience the loss? (Month/Year)
INSOMNIA
Insomnia
- Difficulty getting to sleep
- Cannot stay asleep
- Sleep walking
DESIRED EMOTIONS THAT ARE ABSENT
Desired Emotions That Are Absent
- Happiness
- Excitement
- Love
- Focus
- Confidence
- Motivation
- Relaxation
- Comfort
WEIGHT
Present Weight
Desired Weight
Weight
- Weight problems
- Eat too much
- Sweets
- Junk food
- Not enough exercise
- Dissatisfied with appearance
Why are you dissatisfied with your appearance?

RELATIONSHIPS
Relationships
- Quarreling with family
- Unhappy marriage
- Divorce
- Relationship breakup
- Difficulty meeting people
- Difficulty keeping friends
- Trouble with children
- Trouble w/ loved ones
- Sexual difficulties
PROFESSIONAL
Present Income
Desired Income
Professional
- Fear of public speaking
- Desire a promotion
- Business Job
- Work too dull
- Afraid to take risks
- Blame others
- Want to know my life mission
- Need more goals
- Lack of skills
- I am not assertive
- Sales enrichment
- Sales phone reluctance
- Too pessimistic
- Legal problems
- Lack organization
- Lack communication with staff
- Want to change
What item/s do you want to change?
Check below if you would like to learn more about self hypnosis
Yes, I want to learn more about self-hypnosis
- Yes, I want to learn more about self-hypnosis
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