Hypnotherapy New Client Questionnaire

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone

Private Health Care Provider

Date of Birth

How did you fid out about us

If referred : the persons name who referred you

Have your sort Hypnotherapy/Coaching previously

If Yes, what did you seek it for and how did you find the process? Did you find it beneficial?

What are your main areas of concern that you would like me to address?

Are you medicated for these issue/s?

If yes, what medications are you currently taking?

How would you rate your current stress level? (10 being the highest)

Selected Value: 0

Explain your current stressors if you have any, (eg work, relationship, family loss, financial)

Due you suffer from any long term pain? (if yes please rate with 10 being the highest)

Selected Value: 0

Female Clients only ( Are you currently Pregnant?)

Can you explain your past history regarding the areas of concern you wish to address.

Is there anything else that you feel is important for me to know?

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