Hypnotherapy Client Intake Form

Information you will need

• Do you want to upload an image? af image
• What's your date of birth?
• What's your street address?
• What city do you live in?
• What state do you live in?
• What's your e mail?
• What's your gender?
• What’s your occupation?
• Who's your emergency contact?
• What's your relationship status (if not listed)?
• What's your phone number?
• CLIENT ONLY: What's your name?
• What's your emergency contact's phone number?
• Have you been hypnotized before?
• How was your previous hypnosis experience?
• What do you hope to achieve through hypnosis?
• What are your fears or phobias?
• Are you spiritual or religious?
• What's your belief system?
• Do you have children?
• What's your ZIP code?
• How old are your children?
• How many drinks do you have per week?
• Do you drink alcohol?

…and 62 more fields in the PDF.

Completed by the client.

The form includes 1 signature line.