HYPNOSIS & EMOTIONAL FREEDOM
Jane Anthony Buckman, CHt
703 346 4606 email: Web Site: www.hypnosisva.com
CONFIDENTIAL CLIENT INTAKE FORM
NAME: ______Date:______
Phone: HOME ______WORK# ______CELL# ______TEXT______
ADDRESS: ______CITY:______STATE:_____ ZIP:______
D.O.B.____/____/____ SEX: ____ MARITAL STATUS: ______Spouse/Significant Other: ______
E-MAIL(s) :______WEB SITE______
OCCUPATION:______COMPANY:______
EDUCATION:______
How did you hear about us?______
FAMILY: Children:______; Brothers_____ Sisters____; Parents (living?) : ______
Other members of household and age:______
Has anyone tried to hypnotize you?______Reason:______
Do you believe that you were hypnotized? _____ Why?______
THE MAIN ISSUE I AM COMING HERE FOR:______
Any previous attempts to address this issue? _____ If so, the Results:______
Are you currently undergoing medical or psychological treatment for the above issue? ______
Have you been treated for emotional problems? ______
Have you seen a therapist for these or any other issues? ______
What, if any, medications are you taking?______
Have you had any prolonged illness? ______
*Check all issues you would like to work on. Place an X by the most urgent issues:
___Confidence/Self-Esteem ___Fears or Phobias
___Depression or Grief ___Fear of Public Speaking; Social Phobia; Shyness
___Weight Issues ___Procrastination
___Smoking Cessation ___Past Trauma or Painful Memory
___Addictions or Negative Habits ___Chronic or Current Pain
___Stress/Anxiety/Insomnia ___Blocks to Self-Actualization
___Relationship Challenge(s) ___Insomnia/Low Energy
___Anger, frustration or Resentment Other:______
áWe find it useful to sometimes use a holistic approach (mind-body-spirit) when appropriate. Would you consider yourself a spiritual person? ______
I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of self-improvement. I understand that the hypnosis I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnosis with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my medical doctor for treatment of any new or old illnesses. Sessions may be recorded for our protection and for yours.
Any appointment changes need to be made two business days in advance.
Appointments broken or canceled without the two business days’ notice will be charged for the session.
______
Client Signature Parent/Guardian Signature (if under 18 years old)
Intake Questions:
Please tell me everything you think I should know about the main issue you want to work on first.
Write as much as you can think of – the more information you give me ahead of time - the faster we can move forward.
My Main Issue is:
What does this issue prevent you from doing or enjoying?
What does it feel like?
When do you feel it?
When was the first time you noticed the problem?
What else was going on in your life when this issue came into being?
What do you think is the cause of it? What insights do you have about it?
I know of a past experience or relationship that could be causing this problem.
I am aware of an internal conflict that may be causing part (or all) of my problem.
How do you think/ feel about it?
Has this been a pattern in your life?
What is the upside, if any, of having this problem?
If you changed this part of your life, what new problems might that bring?
Who might be harmed or unhappy if you changed that part of your life?
What would be different about your life if you overcame the problem?
Anything else you can think of regarding it?
PLEASE ANSWER THE FOLLOWING THOUGHT PROVOKING QUESTIONS:
If you were to live your life over, what person or event would you prefer to skip?
What are the most dramatic events (emotional or physical) that have happened to you? Identify them in a way that makes sense to you and provide details if you wish.
What makes you angry and why?
When was the last time you cried and why?
What is your biggest regret or sadness?
Name three fears that you would rather not have:
What would life be like if you were free from this issue?
If I wasn’t so much like ______, I’d be much happier.
TO DESCRIBE HOW THOSE CHANGES WILL BENEFIT YOUR LIFE. How will these changes affect your life?
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