Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Personal Status (check one)

Married

Single

Divorced

Gay

Lesbian

Bi-Sexual

Other

Name of partner

Names and ages of children

List your three favorite colors in order of preference

List your three favorite places in order of preference

On a vacation do you prefer relaxation or excitement?

List any fears/phobias

Do you experience any compulsive tendencies?

List any current health problems

Are you being treated by a health physician? If yes, what?

Are you being treated by a psychologist/psychiatrist? If yes, for what?

List any medications you are taking.

Please list your three most important life-time goals

Please list your three favorite past-times/hobbies

What is your current occupation?

Do you enjoy your work?

Please list things that you like to do but that you want to be better at.

If you could be, do, have or become anything, what would you wish for?

Why are you seeking hypnotherapy?

How did you hear about our company?

Do you follow any religious or meditative practices? (if so, please describe)

Please list any other conditions occurring in your life that you believe are negatively effecting you in any way

Please use additional space to tell us specifics of your needs/concerns, if necessary

Release Statement

I hereby authorize True North Hypnosis LLC to hypnotize me for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability to relax and desire to create change in myself. I understand that because the results of my sessions depend greatly upon my own serious participation that True North Hypnosis LLC cannot offer any guarantee of the success of my treatment. I am aware, however, that True North Hypnosis LLC will do everything reasonably in their power to ensure my success. Signed:

By entering your first and last name, you are electronically signing our release statement and submitting by email to our office

First Name

Last Name

True North Hypnosis & Wellness

Prior to your first session, please complete and submit your client questionnaire to us.