Confidential Intake Form Field marked with * are required Name (First & Last) * Phone Number* Email* Street Address * Address Line 2 City* State* Select a state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside the U.S. Zip Code* Gender Select an option... Male Female Other/ Prefer not to say Other Gender (optional) Birthdate* Referred By Employer Occupation Emergency Contact - Name (First & Last) * Emergency Contact - Phone Number* Emergency Contact - Relationship * Do you consider yourself stressed? Select an option... Yes No On average, how many glasses of water do you drink per day? Have you ever received hypnotherapy services before? * Select an option... Yes No If so, by whom? Have you ever used the services of psychotherapy? Select an option... Yes No Have you ever been diagnosed with schizophrenia? Select an option... Yes No Please list any medication (vitamins, herbs or pharmaceutical) taken now or at regular intervals. Include an explanation of what the medication is used to treat. Please list any conditions that currently affect you, or that you have experienced within the last 2 years. * Anemia Asthma Anxiety Dizziness Fibromyalgia Headaches Indigestion Irritable Bowel Syndrome Heart Condition Hypertension Insomnia Numbness/Tingling/Twitching Pain Panic Attacks Seizure Disorders Spinal Cord Injury TMJ Trouble Breathing Ulcers Other / Not Listed None Please describe What are your purposes for seeking hypnotherapy today? * How do you prefer your appointments? * Select an option... In Person Virtual Agreement By typing my name below, I understand and agree that this constitutes a legally binding electronic signature equivalent to a handwritten signature. Signature* Send Message
