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Client Questionnaire
Client Questionnaire
SHAdmin
2020-04-08T23:53:46+00:00
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GENERAL CLIENT INFORMATION
Items with an
*
are required.
Name
*
Age
Date of Birth
Day
Month
Year
Email
*
Primary Phone
*
Secondary Phone
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
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Date
*
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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