Kinconnxon Hypnotherapy Intake Form

General Info

First name

Last name

Age

Phone

Address

Time Zone

How did you find me?

Have you been hypnotized before?

yes

What was that experience or experiences like for you?

What is your reason for hypnotherapy today, in one sentence?

What are you hoping to shift? Be as specific as you can. Specificity gives us more to work with.

How long has this been a part of your life?

If this changed, what would be different six months from now? Put your answers in practical, concrete terms if possible.

What have you already tried? Please share what has helped even slightly, and what hasn't?

Is there any part of you that is hesitant about changing this?

Getting to Know You

When you think of a 'good day', what arrives first? -Images, sounds, a specific memory, a feeling or sensation, words, or something else?

If I asked you to imagine biting into a lemon, what happens for you?

Are you aware of an ongoing inner voice or commentary?

If so, please describe the tone of it.

When you are trying to work out an issue, do you think in words, in images, or experience sensations?

Health History

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.

Any history of seizures, head or brain injury, or neurological conditions?

Do you have any physical ailments or concerns we need to consider in our work together?

Have you or do you currently work with a therapist or counselor?

What is your relationship to alcohol, or any mind-altering recreational or ceremonial substances? How often do you partake? (Your answers to this and all questions are confidential).

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

Personal History

Are there any experiences in your past that still affect you today, that I should know about?

You don't need to write details here. a sentence or a few words is enough. If there is anything you'd rather say out loud, we can cover that when we meet.

Do you have any specific fears or phobias?

Recurring nightmares or dreams?

Are there certain words, images or topics that you would want me to avoid?

Your Nervous System Wiring

How often is stress a real problem for you?

always

often

sometimes

rarely or no

Periods of depression or flatness?

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...

What happens for you when you try to relax using meditation, breathwork, or other methods?

Some people are able to settle and respond to relaxation techniques. Others get more activated. Which are you?

What helps you come back down when you get activated, upset, or irritated?

Our Session

Below are the recommended guidelines for our session. Please check all that apply for you.

I will be somewhere private where I won't be interrupted

I will have headphones

I can fully recline or lie down comfortably

Anything else that feels relevant to share for our work together?

Thank you for sharing this information. It will assist me in tailoring your treatment appropriately. By signing you confirm that you understand that hypnotherapists do not provide medical or mental health diagnosis or counseling. Hypnotherapy works with your own subconscious processes and as a facilitator of this work, I help guide you in this process.

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, I 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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