Client Intake Form

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Personal Information:

Name

First

Last

Preferred Name

Phone

Gender

Date Of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation

Marital Status

Hobbies & Interests

What do you do to relax

What are your Strengths?

What are your Weaknesses?

Medical Information

Doctors Name

Permission to contact Doctor

Doctors Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Relevant Medical or Psychiatric History

Are you currently taking Prescription Medication? (if Yes, Please give details)

Over Counter Medication

Recreational Drugs

Smoker / Non-Smoker

Alcohol Intake

Therapy / Hypnosis History

Are you currently receiving any other Therapy? (Related or Unrelated to issue. If Yes, Please give details)

Have you experienced Hypnosis before? (If Yes, Please explain experience)

What is your knowledge of Hypnosis?

Reasons and Goals for Therapy

What is the reason for Therapy?

Details of Issue / Symptoms

How does the Issue effect your lifestyle?

How does the Issue effect your Personal Relationships?

What improves Issue / Symptoms

What is your overall Goal for Therapy?

How did you hear about us? (If referred, who referred you? )

Declaration

I confirm that the information provided is to the best of my knowledge current and accurate. I agree that if any of this information should change I will update my therapist at the earliest convenience.

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Opening Times

Weekdays:

8am – 7:30pm

Saturdays:

10am – 3pm

Contact

07877 056 778

rossnosis@gmail.com

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