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Note: All information will be kept strictly confidential except that which I am legally obligated to report, such as threat of injury to yourself or others. If you are in any way uncomfortable with any of these questions, feel free to skip them. Please be aware that the more you tell me about yourself, the more I may be of assistance to you. Feel free to use additional paper to go into detail about anything you wish me to know about you.
It is my honor to assist you.
Name: _______________________________________ Sex: ____
Date of Birth: _________________ Place (city & state/country) of birth: _____________________________________
Time of Birth: ____________________ (check one) ___ am ___ pm
Address: _______________________________________ City: _______________________ State: _____ Zip: ______
Daytime Phone: __________________ Evening Phone: ___________________
Personal Status (check one): __ Married __ Single __ Divorced __ Other Committed Relationship
Sexual Preference (check one): __ Heterosexual __ Gay __ Bi-Sexual
Please list the Names and Ages of any children: __________________________________________________________
Name of Partner: _________________________________
1. List your three favorite colors in order of preference.
2. List your three favorite places in order of preference.
3. On a vacation do you prefer relaxation or excitement?
4. List any fears or phobias.
5. Do you experience any compulsive tendencies?
6. List any current health problems.
6a. Are you being treated by a physician? ____ Yes ____ No
If yes, for what?
6b. Are you being treated by a psychologist/psychiatrist? ___ Yes ___ No
If yes, for what?
7. List any medications you are currently taking.
7a. List any herbs, vitamins or supplements you are currently taking.
8. Please list your three most important life goals.
9. Please list your three favorite past-times/hobbies.
10. What is your current occupation?
11. Do you enjoy your work?
12. Please list things that you like to do but that you want to be better at.
13. If you could be, have or become anything, what would you wish for?
14. Why are you seeking hypnotherapy?
15. How did you hear about my hypnotherapy services?
16. Are you currently experiencing any of the following (check all that apply)
__ nervousness __ inability to relax __ sleeplessness __ depression __ sexual dysfunction __
compulsive tendencies
__ nail biting __teeth grinding __ nightmares __ poor health __ cigarette smoking __ alcohol abuse __ drug abuse
__ compulsive overeating __ self-mutilation __ serious eating disorder __ co-dependency
__ inability to focus attention __ poor memory __ marital problems __ recent divorce __ war trauma
__ current illness or recent death of a loved one __ childhood trauma __ fear of heights __ lack of energy
__ poor self-esteem __ abusive home situation __ ADD or ADHD __ abusive work situation __ lack of success
__ other: _____________________________________________________
17. Do you follow any religious, spiritual or energy/healing meditative practices? If yes, please describe.
18. Please list any other conditions occurring in your life that you believe are negatively affecting you in any way.
On a separate sheet(s) of paper, create a list of people in your current life from your past and present. This "cast of characters" should be the people who are important to you - family members, friends, co-workers, teachers, mentors, lovers, spouses, children, pets. Anyone who has helped to shape your life - positively or negatively. List their name, their relationship to you, a paragraph about how they have helped form your life (for example, what you have learned from the relationship), and a few words that describe their character.
If you have any questions about this form, please call me at (651) 771-4477.
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