Kinconnxon Hypnotherapy Intake Form

General Info

First name

Last name

Birthday

Month

Day

Year

Phone

Address

Have you been hypnotized before?

yes

Date you were last hypnotized

Reason for hypnosis

Please list your CURRENT goals for hypnotherapy and include detail on the issues you would like to work on. Please share as much as you can!

Personal Health History

Have you been diagnosed with any physical or mental health issues, either past or present?

What, if any, serious accidents, injuries, or illnesses have you experienced in your life? Please include the year and details.

Are you aware of any big traumas you have experienced in your lifetime? Please include the year, and any details you recall.

Do you have any specific fears or phobias that you are aware of? Please include any recurring dreams or nightmares you may have had.

Please list any prescriptions, or OTC drugs you are taking.

Are you currently under the care of a doctor, nutritionist, or other physical or mental health professional for any specific issues? Please explain, if so.

Do you have any known addictions?

General Wellness

Is stress ever a major problem for you?

always

often

sometimes

rarely or no

Do you ever feel depressed?

always

often

sometimes

rarely or no

Do you experience anxiety or panic?

always

often

sometimes

rarely or never

Do you have issues with sleep?

always

often

sometimes

rarely or no

Please provide more detail about any sleep issues you have...

Have you ever been to therapy? Please provide detail into the basis and duration of any counseling or therapy you have received.

Do you drink alcohol, or use any mind-altering recreational or ceremonial substances? Please provide detail and how often. Reminder that your answers are strictly confidential.

Physical Issues

Please share any other information you feel is relevant to our work together.

Thank you for sharing this information. This information will assist me in tailoring your treatment appropriately. By signing you are confirming that you understand that hypnotherapists do not provide medical or mental health diagnosis or counseling, we simply guide you to find the answers that already exist within your subconscious mind.

You also understand that you have complete free will and therefore your level of participation and openness also plays a part in the outcome of our sessions. As a result, we cannot guarantee any specific outcomes, and we cannot always predict what the subconscious mind or the conscious mind might choose to focus on during a session. By signing you are also releasing me, Kayt Pearl and my business, Kinconnxon, of any liability for any outcome that may result from our work together.

By checking this box I agree to the above statements and attest that I have shared all of my personal information truthfully, and to the best of my ability.

Yes! I want to receive your newsletter including events, updates, research and wellness tips. (please uncheck this box if not)

Date

Month

Day

Year

Signature and Printed Name

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