Start your Journey

Intake

Begin Your Transformative Journey

Welcome to Acadian Rock Hypnosis. Completing this intake form is your first meaningful step toward positive change through the power of hypnotherapy. This confidential information helps me understand your unique needs and goals, allowing me to create a personalized approach for your sessions.

After submitting this form, you can schedule your first session, after which full payment is required with a 24 hour cancellation policy. Cancellations made less than 24 hours before the appointment are non-refundable.

My approach combines traditional hypnotherapy techniques with modern neuroscience to help you access your subconscious mind and create lasting change. Whether you’re seeking relief from stress, breaking unwanted habits, or exploring personal growth, I’m here to guide you on your journey.

Please complete all required fields below to begin the process.

    Hypnotherapy Intake Form

    Thank you for choosing Acadian Rock Hypnosis. Please complete this intake form to help me better understand your needs and provide the most effective care. All information is confidential.

    Personal Information

    Full Name:

    Date of Birth:

    Gender: (Please select from the dropdown)

    Email Address:

    Time Zone:

    Medical and Mental Health History

    Have you been referred by a healthcare professional?

    YesNo

    If yes, please provide their name and contact information:

    Are you currently receiving therapy or counseling?

    YesNo

    If yes, please provide details:

    Do you have any diagnosed medical or mental health conditions?

    YesNo

    If yes, please list them:

    Are you currently taking any medications?

    YesNo

    If yes, please list them:

    Background and Goals

    What is your primary reason for seeking hypnotherapy?

    On a scale of 1 to 10, how ready are you to make changes in your life? (Please select from the dropdown)

    Have you ever been hypnotized before?

    YesNo

    Do you have any practices or hobbies that support relaxation or self-care?

    Is there anything else you would like me to know before our first session?

    Consent and Agreement

    Please read and check each statement:

    I understand that hypnotherapy is not a substitute for medical or psychological treatment.

    I consent to participate in hypnotherapy sessions.

    I understand that all information I share will be kept confidential, except in circumstances where I am legally required to report such as cases involving risk of harm to self or others, child or elder abuse, or if ordered by a court of law.

    I understand that results may vary and that my active participation is essential to success.

    Digital Signature:

    Date:

    Thank you for completing this form. I look forward to supporting you on your journey to healing and empowerment.

    ©2025. Acadian Rock Hypnosis. All Rights Reserved.

    Privacy Policy
    Terms & Conditions