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)

—Please choose an option—FemaleMaleNon-binaryPrefer not to sayOther

Preferred Pronouns:

Address:

Phone Number:

Email Address:

Emergency Contact Name:

Emergency Contact Phone Number:

Referral Information

How did you hear about Acadian Rock Hypnosis?

—Please choose an option—Internet SearchSocial MediaFriend/FamilyHealthcare ProfessionalAdvertisementOther

Have you been referred by a healthcare professional?

YesNo

If yes, please provide their name and contact information:

Current Concerns

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

—Please choose an option—1 (Not Ready)2345 (Somewhat Ready)678910 (Very Ready)

What is the primary reason for seeking hypnotherapy?

Have you experienced sexual trauma or issues you'd like to address?

YesNo

If yes, please describe briefly (only share what you're comfortable with):

Are there any other challenges or goals you'd like to address?

Medical and Mental Health History

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:

Have you ever been hypnotized before?

YesNo

If yes, please describe your experience:

Lifestyle and Background

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

Are there any cultural, spiritual, or personal beliefs I should consider during our sessions?

Is there anything else you'd like me to know about your background or experiences?

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.

Please leave this field empty.

Δ