Hypnosis General Information Form

Comments

This field is for validation purposes and should be left unchanged.

Personal

Name*

First Last

Email*

Enter Email Confirm Email

Phone number (preferred)*

Type

Alternate phone

Type

What time zone are you in?*

Age*

Date of birth*

Month

Day

Year

Gender identity*

If referred, by whom?

Family

Relationship Status*

Single

Married

Divorced

Widowed

Other

Name of spouse or partner

First

Do you have children?*

Yes

Children

Name

Age

Gender identity

Vocation/Education/Interests

Occupation*

Brief work history*

Education*

Military service*

Yes

Retired military

Other

Hobbies and interests*

Please briefly describe your spiritual or religious beliefs or life philosophy*

Physical Health

Do you consider yourself in good physical health?

Yes

Other

If no, please explain*

Medical conditions& history*

Briefly list or describe

Are you currently taking any prescription medication?*

Yes

List current prescriptions*

Are you currently under a physicians care?*

Yes

If yes, please specify for what condition(s)?*

Do you smoke or use any other form of tobacco or nicotine?*

yes

If yes, please provide some details?*

Do you smoke, vape, patches, etc? How much? How frequent?

Do you drink alcoholic beverages/*

Yes

If yes, how much and how often?*

how much per day/week/month:

Recreational or therapeutic drug use?*

(Marijuana, CBD, THC...)

Yes

If yes, please provide some details:*

Mental Health

Are you in good mental health?*

Yes

If no, please explain:*

Have you ever received treatment for a mental health condition?*

Yes

If yes, please describe any mental health condition(s) and treatment:*

Have you ever taken prescription drugs for anxiety, depression, or any other mental health problems?*

Yes

If yes, please list prescription drugs:*

Ona scale of 1-10, 10 being the maximum how would you rate your stress/anxiety?*

Please enter a number from 1 to 10.

Briefly describe the causes of stress/anxiety:*

*Note

If you are seeking treatment for a medical issue it may be necessary to obtain your physician’s approval to use hypnosis or BWRT® as an adjunct to medical treatment. Let’s discuss this before your first session.

General

Do you use relaxation techniques such as meditation, mindfulness, breathing techniques or prayer?*

Yes

Sometimes

Briefly describe technique(s) you use and frequency*

Have you had Hypnosis or BWRT® previously?*

Yes

If yes, when? For what? Was it helpful?*

Please give your reason(s) for seeking BWRT® or hypnosis:*

Any particular questions or concerns that you may have about BWRT® or hypnosis?*

Choose all that apply*

Sports related

Education/study/test related

Public speaking

Procrastination

Choose all that apply*

Vocation/career/business related

Health related

Stress/Anxiety related

Relationship related

Choose all that apply*

Weight loss

Smoking cessation

Alcohol related

Fears and/or phobias

Please share any additional information that you feel might be helpful for me to know?

Woman Owned Small Business

Hypnosis General Information Form

Personal

Family

Vocation/Education/Interests

Physical Health

Mental Health

*Note

General

Woman Owned Small Business

Talk to Trisha: 360-885-1965