Intake Form
[field id="name"]
Client Name:
[field id="field_a2f69e8"]DOB:
[field id="field_0dc197d"]Age:
[field id="field_ce8acec"]Address:
[field id="field_2be745d"]City:
[field id="field_039397c"]States:
[field id="field_1ac02e6"]ZIP:
[field id="field_9342771"]Email:
[field id="email"]Best days and times for future sessions:
[field id="field_88415c0"]What is the main issue you wish to resolve with hypnotherapy?
[field id="field_c78e63b"]Have you experienced hypnosis before? If yes, please briefly describe your experience.
[field id="field_91448bb"]Were you referred to me? If yes, by whom?
[field id="field_3b7d2c5"]Issues I would like to resolve:
[field id="field_416f4b9"]Other issues/ concerns:
[field id="field_5bcb755"]Have you ever had any mental health treatment, such as with a counselor, therapist, psychologist or psychiatrist?
[field id="field_2511587"]What would your ideal life look like?
[field id="field_d0eef15"]If yes, give a brief history of your mental health treatment and the results of your treatment.
[field id="field_7ebdff1"]What parts of your life are working best now?
[field id="field_8e1cf64"]Are you receiving mental health treatment now?
[field id="field_43bde56"]What parts of your life are working least well now?
[field id="field_0972cb8"]Name of mental health professional
[field id="field_69b61a4"]What are your core values?
[field id="field_27ff608"]Do you have thoughts of hurting yourself or taking your own life?
[field id="field_7400587"]What stops you from having the life you want to have?
[field id="field_010e18a"]Medical conditions/challenges
[field id="field_03e560e"]Are you currently under a physicians’ care for any of the above conditions?
[field id="field_bf99497"]Are you currently under a physicians’ care for any of the above conditions?
[field id="field_bf99497"]Agreement: As a general practice, it is necessary for everyone taking part in private sessions, classes, workshops and seminars with Medical Hypnotherapist, Vanessa Gonzalez, to sign this release of Liability Agreement. I, the client/ co-therapist, agree to all of the statements below:
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