Intake Form

Guidance for Completion

Please take a few moments to complete this form as openly and thoroughly as you can before our first session.

Your responses will help me better understand your needs, goals, and how to tailor our hypnotherapy sessions to support you effectively.

All information shared is treated with the strictest confidence and handled in line with professional and legal standards.

If you're unsure about any question, feel free to leave it blank or write "not sure"—we can explore it together during our session.

Client Information

Title

Full Name

Phone Number

Date of Birth

Age

Address

Occupation

How did you find me ?

General Health & Lifestyle

I understand that I am responsible for checking with my GP or prescribing professional if my health or medication may affect my suitability for hypnotherapy.

Yes

Did your doctor refer you or are they open to hypnosis?

Yes

Please describe

Have you ever received therapy or counselling before (including hypnotherapy)?

Yes

Please describe when and for what purpose

Do you use any substances (alcohol, tobacco, recreational drugs)?

Yes

Please provide details if relevant

Presenting Concerns

What is the main reason you are seeking hypnotherapy?

How long have you been experiencing this issue?

When this issue occurs, please complete the following with as much information as possible

What are the symptoms like?

How long do the symptoms last?

How often does this issue occur?

Where do the symptoms occur?

How do you feel when symptoms occur?

What is the sequence of events?

What was happening in your life at the time this began or just before?

Have you had any major changes, losses, or stresses over the past 5 years. recent life-changing events such as deaths, divorce, relationships, job changes, health issues, past trauma, accidents, etc.?

Have you tried anything else to address it? If so, what was helpful or unhelpful?

What would you like to achieve from hypnotherapy?

Please describe your ideal outcome

Imagine when you go to sleep one night and something happens, and the issue has disappeared. Because you were asleep you did not know what or how this happened. When you wake up what would be the first signs for you that something has happened?

Client Preferences & Expectations

Have you ever been hypnotised before?

Yes

If yes, what was your experience like?

Are there any specific concerns or fears about hypnotherapy you'd like to discuss?

If you have been hypnotised, do you prefer a direct or indirect approach in hypnosis (more directive suggestions vs. metaphorical/story-based)?

Direct

Indirect

Not sure

Consent & Agreement

Please read and sign below to indicate your understanding and consent:

I understand that hypnotherapy is a complementary therapy and not a substitute for medical or psychological treatment.
If I think that any medication or health condition could affect hypnotherapy, I understand that it is my responsibility to speak to my GP or the professional who prescribed my medication before going ahead
I consent to participating in hypnotherapy sessions and understand that results vary between individuals.
Appointments are scheduled for your benefit and the benefit of my other clients. Your time is scheduled for you. If you are unable to attend, please let me know as soon as possible so that the time can be rescheduled. If you are delayed, please let me know as soon as possible .
I understand that I may withdraw consent and discontinue sessions at any time.

Consent: By signing this form, you acknowledge that you have been informed about the nature and purpose of hypnotherapy. You understand that hypnotherapy is a cooperative effort between the therapist and the client, and you agree to participate fully in the process.

Client Signature

Date