Client Intake Form

AVALON HYPNOSIS CENTER – CLIENT INTAKE FORM

Name_________________________________ Date___________ Address______________________________________________ City_______________State____ Zip_________ Phone /Cell____________________ Age ____Sex – M – F    Marital Status ____ Children_____                                                                 How did you hear about us?    _____Yellow Pages____ Internet ____Referral      Name________________________________ Have you ever been hypnotized?        Y – N                                                 What is the main reason you want hypnosis        _________________________________________________

MEDICAL HISTORY         Check any of the following that may apply to your physical or mental attitude.   Please check  Any Fears you may be uncomfortable with. Check  any Changesdesired..                                     PHYSICAL HEALTH  :     

____ Allergies         ____ Diabetes        ____Heart Problems

____Epilepsy          ____Migraines       ____Headaches

____Smoker            ____Nail Biter        ____Low Energy

____Flushing         ____Body Pain       ____Unexplained Pain

____IBS                      ____BodyAche       ____Hearing Problems   

FEARS:

____Lightning     ____Bridges              ____Animals          

 ____Men                ____Women               ____Avoid Cracks  

____Dogs               ____Darkness            ____Fear Surgery   

____Highways   ____Driving               ____Fear Doctors

____Of Not Pleasing Others                  ____Body Fluids

____Flying           ____Dentistry        ____Public Speaking

____Spiders        ____Birds                   ____Sting Insects 

____Bugs             ____Lizards               ____Fear Death 

____Snakes        ____Frogs                   ____Site of Blood 

____Heights      ____Stairs                   ____Escalators 

____Elevators ____Climbing           ____Water/Swimming 

____Hate             ____Fear Germs     ____Going Out

____Intimacy

List any other thoughts_________________________________

MENTAL ATTITUDE:

____Missing Time       ___Feel Inadequate   ____Suicide Thoughts

____Angry Thoughts ___Highway Anger   ____Hear  Voices           

____Nightmares            ___Insomnia                ____Poor Memory   

____Do Drugs/Did       ___Abuse Alcohol     ____Being Touched 

____Being Alone          ___Poor Concentration    ___ Hair Pulling 

____Hair Twisting     ___Embarrass Easily  ___People to Close 

____Hand Washing  ___ Closed in Spaces    ___ Were you Adopted 

____Chewing Mouth ___Skin Picking           ___Hear Mumbling 

____Depression         ___Reoccurring Dreams ___Mood Swings 

____P.T.S.D.                 ___Impulsive Behavior  ___ Hear Voices 

___Panic Attacks ___Rambling Thoughts  ___Negative Thoughts

___Anxiety             ____Past Abduction 

List any other Thoughts_________________________________

CHANGES DESIRED IN YOUR LIFE

___Stop Smoking          ___Lose Weight              ___Control Stress

___Sleep Better              ___Enhance Learning ___Test Easier

___Increase Energy  ___Control Pain                ___Control IBS

___Improve Memory ___Self Confidence     ___Personal Healing

___Increase Sales       ___Sports Enhancment ___Stage Fright

___Positive Thinking ___Creativity                  ___End Grief

___Find Your Joy       ___Self  Hypnosis             ___Control Drug Use

___Study Habits            ___Spiritual Growth    ___Rid Writers Block

___Stop Nail Biting     ___ Control Alcohol     ___Healing

___Cancer Contol       ___Peace

PLEASE COPY AND FILLOUT  AND BRING TO APPOINTMENT