Name
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First Name
Last Name
Date of Birth
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Sex/Gender
What are your preferred pronouns?
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
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Relationship status
Name of partner
Name and ages of children
List your three favorite colors in order of preference
List your three favorite place in order of preference
On a vacation do you prefer relaxation or excitement?
Please list any fears or phobias.
Do you experience any compulsive tendencies? If so, please describe below.
Please list any health problems I should be aware of.
Are you currently being treated by a physician?
If yes, for what?
Are you currently being treated by a psychologist/psychiatrist/therapist/counselor?
If yes, for what?
List any medications you are currently taking.
List any herbs or vitamins you regularly ingest.
Please list your three most important life goals.
Please list your three favorite past-times/hobbies.
What is your current occupation?
Do you enjoy your work?
Please list things that you like to do but you want to better at:
If you could be, do, have or become anything, what would you wish for?
Why are you seeking hypnotherapy/hypnosis?
How did you hear about me?
Are you currently experiencing any of the following (please check all that apply):
If there is something missing from the list above that I should know about, please list it below.
Do you follow any religious or meditative practices? If so, please describe.
Please list any other conditions occurring in your life that you believe are negatively affecting you in anyway.
Is there anything else I should know that we have not covered in the form above? Please use this space to do so.
RELEASE STATEMENT: I hereby authorize Mary D’Alba to hypnotize me for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability to relax and desire to create change in myself. I understand that because the results of my sessions depend greatly on my own serious participation that Mary D’Alba cannot offer guarantee of the success of my treatment. I am aware, however, that Mary D’Alba will do everything reasonably in her power to ensure my success.
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By checking the Yes box below, I'm agreeing to the release statement above.
Please select today's date.
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AUDITORY LEARNING CHANNEL INDICATORS
Please check the box of any item that seems like something that fits your nature.
VISUAL LEARNING CHANNEL INDICATORS
Please check the box of any item that seems like something that fits your nature.
STRONG IN TOUCH/MOVEMENT (KINESTHETIC) CHANNEL
Please check the box of any item that seems like something that fits your nature.
