Online Hypnotherapy Intake Form

Initial Hearing Sheet

The information you provide will be used only to ensure a safe and effective session, and will not be shared with third parties. Feel free to leave any item blank if you prefer not to answer.

You can fill this in directly on screen. When you are finished, use the "Print / Save as PDF" button at the bottom to save a copy, and send it to us by email. Nothing you type here is stored on this page — please save before closing.

1 Basic Information

Full name

Date of birth

Age

Gender

Address / area of residence

Occupation

Phone number

Email address

How did you hear about us?

Search (Google, etc.) Social media Referral Other

2 About the Session

Is this your first time receiving hypnotherapy?

Yes, first time No, I have experience

If you have experience: when, and what kind of session

Preferred session platform

Zoom Google Meet

Preferred date/time (1st choice)

Preferred date/time (2nd choice)

3 Your Concern

Please describe, as specifically as you can, what you would like to work on or are concerned about in this session.

Approximately how long has this been going on?

What change or outcome would you like to experience through this session?

4 Health and Safety Check

Asked in order to keep the session safe.

Are you currently seeing a psychiatrist or other mental health provider?

No Yes

If yes: diagnosis / treatment (as much as you know)

Are you currently taking any medication?

No Yes

If yes: name of medication / purpose (as much as you know)

Do any of the following apply to you?

Have you ever received counselling or psychotherapy before?

No Yes

5 Emergency Contact (optional)

Name (relationship to you)

Phone number

6 Agreement

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

If I have a pre-existing condition, I agree to obtain my physician's approval before the session.

I understand that any personal information shared during the session will be kept confidential and not disclosed to third parties without my consent.

I understand that the session may be interrupted due to online connectivity issues.

I agree to the cancellation policy (please notify at least 24 hours before the session).

Signature

Date

Thank you for completing this form. We will review your responses and confirm your session schedule.