New Client Intake Form
Please Print, fill out completely, scan/photograph and email to firstname.lastname@example.org
Date: ___________________ Date of Birth: ___________________Age__________________
Best Phone: _________________________________ SecondaryPhone:__________________
Best Email: __________________________________________________________________
Emergency Contact and phone number____________________________________________
Is this your first time being hypnotized? Y/N, If No, how was your previous experience(s)? _____________________________________________________________________________
Occupation: _______________________ Employer:___________________________________
Marital Status: M____ S____ D ____ Sep___ W____
Children: (How many/Ages)? Male(s) ______________________ Female(s)_______________
Well-loved pets (TypesNames)____________________________________________________
Hobbies and interests: __________________________________________________________
Please answer the following questions
1. Where did you hear about ? (Please check all that apply.)
[ ] Omniji Website [ ] Yelp [ ] Facebook [ ] Twitter [ ] Other Website [ ] Newspaper article/ad, brochure, or other marketing materials: ____________________________________________________
2. When you have benefitted from my hypnosis, would you email me a short testimonial? Y/N
3. What type of learner are you primarily? (If you’re not sure, just go with your gut.)
[ ] Visual
[ ] Kinaesthetic/Feeler
[ ] Auditory
4. Please check all that apply and circle the best answer below: [ ] Creative
[ ] Analytical
[ ] Social
[ ] Problem Solver
[ ] Introverted
[ ] Extroverted
[ ] Other. Please explain: ________________________
5. My dominate hand is: L R A
6. I mainly consider myself pragmatic/evidence based, spiritual/belief-based, belief-based but not spiritual, or Other. Please explain.____________________________________________
What is your presenting issue(s) for seeking hypnotherapy?
When and under what circumstances did this issue begin?
What specifically about your issue is leading you to seek help?
What other kinds of therapies have you tried? Please explain.
What life-style or attitude changes have been at least partially successful?
What other issues, either linked or not linked, to the presenting issue do you need help with?
Have you ever been diagnosed with a mental illness? If yes, please explain:
Have you been under regular medical or psychological treatment in the past year? If yes, please explain:
Have you ever been treated for an emotional/behavioural problem? If yes, please explain:
Have you had or do you now suffer from any prolonged illness? If yes, please explain:
List all current medications you are taking:
Please provide the name(s) and contact information of your current doctor(s) and/or therapist(s):
Have you had or are you suffering from:
High Blood Pressure _____ Ulcers _____ Asthma _____ Stress _____ Epilepsy _____Anxiety _____ Migraines _____ Diabetes _____ Heart Condition ______ Cancer _____TMJ _____ Overweight _____ HIV/AIDS ____ Depression _____ OCD ____ ADD ____ Hypoglycemia _____ Fainting Spells _____ Food Allergies _____ Fatigue _____ Arthritis_____ Spine or Back Problems_____ Other__________________
Are you pregnant? Yes _____ No _____
Drink Alcohol? No _____ Occasionally _____ Moderately _____ Daily _____
Do you smoke cigarettes? ______ Cigars? _____ Pipe? _____ Chew? _____ How much per day? _________________
How many hours of sleep do you get per day on average? ___________________
I, the undersigned, understand all questions and verify that all information is complete and accurate to the best of my knowledge. I also understand that the hypnotic methods used by Hypnotist(s) of Omniji Hypnotherapy are not a substitute for medical or psychiatric treatment. I understand these methods to be a conditioning process, whereby an individual is taught to use their own abilities for their benefit and wellbeing. With this understanding, I hereby grant the Hypnotist(s) of Omniji Hypnotherapy permission to hypnotize me or the minor child whose name appears at the top of this form. I (we) further grant permission for the sessions to be recorded/taped as needed.
I know my progress is dependent upon my efforts and that there are no guarantees as to the result or progress to be made. I understand that the success of the treatment will be in direct proportion to my commitment to the end result.
I (we) agree to pay for services rendered to the above-named client as the charge is incurred.
By signing this document, I am confirming that all information is true to the best of my knowledge, and I agree to all the terms listed above:
I understand that Monica Angelatos is a Certified Hypnotherapist and practices Time Line Therapy , she does not diagnose or prescribe medications, nor gives advise or instruction what to do. Anything discussed during a session is meant as a suggestion to educate, motivate and inspire me to get well. I understand that she does not provide mental therapy as she is not a doctor, psychologist, or councillor. Any suggestions or advice are general and should not be interpreted as a substitute for consulting with medical or mental health professionals. Accordingly, I take responsibility for the consequences of any actions that I might decide to take based on any comments or opinions expressed by Monica Angelatos during the course of therapy sessions.
Client’s signature __________________________________________Date________________
Guardian’s signature (if client is a minor) _______________________Date________________
ALL INFORMATION IS STRICTLY CONFIDENTIAL
Confidentiality: Information about our session will not be discussed or released to anyone without a written authorization from you, except as provided for by law.