Hypnotherapy Full NameDate of Birth MM slash DD slash YYYY AgePhone NumberEmail Address AddressEmergency Contact Name & RelationshipEmergency Contact Phone NumberWhat brings you to hypnotherapy at this time?What specific issue(s) or goals would you like to address? Anxiety Trauma Smoking/Vaping Cessation Insomnia Weight Management Confidence/Self-Esteem Past Experiences/Phobias Other OtherHave you been in therapy, coaching, or other healing modalities before? Yes No If yes, what kind and what was helpful?Are you currently under the care of a mental health professional? Yes No If yes, specifyPast diagnoses (check all that apply) Depression PTSD Bipolar Disorder Panic Disorder OCD Schizophrenia/Schizoaffective Dissociative Disorder None Current psychiatric medications Yes No If yes, listHave you experienced hypnosis before? Yes No If yes, describe your experienceDo you visualize easily? Yes No Unsure Comfortable closing eyes and relaxing in session? Yes No Sometimes Chronic medical conditions? Yes No If yes, explainHistory of seizures, epilepsy, or fainting? Yes No Hearing or vision difficulties? Yes No Do you have a spiritual or mindfulness practice? Yes No If yes, describe brieflyDescribe your sleep Restful Difficulty falling asleep Waking up during the night Nightmares Willing to participate in the process and practice between sessions Yes No Maybe Is there anything else you'd like your hypnotherapist to know? {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…
