Burlington Hypnosis Intake Form

Name

Date of Birth

Sex

Address

City

State

Zip Code

Email Address

Phone - Home

Phone - Cell

Emergency Contact Phone

Secondary Emergency Contact Phone

Why are you persuing hypnosis?

When and under what circumstances did this issue begin?

How has this affected your life and what specifically about your issue is leading you to seek help?

What other kinds of therapies have you tried?

Have you encountered previous experience with hypnosis, meditation, guided imagery or progressive relaxation? Have you encountered previous experience with hypnosis, meditation, guided imagery or progressive relaxation? Yes No

Please describe your previoes experience with hypnosis

Howdid you hear about Burlington Hypnosis? Howdid you hear about Burlington Hypnosis? Website Google Facebook Twitter Other

Enter other here

Have you watched the introduction to hypnosis video? Have you watched the introduction to hypnosis video? Yes No

Are you under psychological care? Are you under psychological care? Yes No

Explain psychological care

Are you experiencing any of the following? Depression, Anger, Anxiety, Hopelessness, Crying, Fatigue, Nightmares, Phobia, Worry, Self-injury, Insomnia, PTSD -- Please rate all that apply below: Are you experiencing any of the following? Depression, Anger, Anxiety, Hopelessness, Crying, Fatigue, Nightmares, Phobia, Worry, Self-injury, Insomnia, PTSD -- Please rate all that apply below: Yes No

Depression DepressionNo problemMinimalOccasionalFrequent

Anger AngerNo problemMinimalOccasionalFrequent

Anxiety AnxietyNo problemMinimalOccasionalFrequent

Hopelessness HopelessnessNo problemMinimalOccasionalFrequent

Crying CryingNo problemMinimalOccasionalFrequent

Fatigue FatigueNo problemMinimalOccasionalFrequent

Nightmares NightmaresNo problemMinimalOccasionalFrequent

Phobia PhobiaNo problemMinimalOccasionalFrequent

Worry WorryNo problemMinimalOccasionalFrequent

Self Injury Self InjuryNo problemMinimalOccasionalFrequent

Insomnia InsomniaNo problemMinimalOccasionalFrequent

PTSD PTSDNo problemMinimalOccasionalFrequent