Hoosier Hypnosis Intake Form
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YOUR CUSTOMIZED PROGRAM
Please briefly describe your goals
YOUR PART OF THE PROCESS...
PERSONAL INVESTMENT & GOALS
Do you understand our scheduling and payment policy?
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Yes
How can we help?
Which of our services best describes what brought you to us?
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Services
Sports/Performance
Stress / Anxiety
Addiction
Quit Smoking
Life Coaching
Depression
Insomnia / Sleep
Chronic Pain
Study Effectively
Weight Loss/Healthy Habits
Fears / Phobias
Trauma
Other/Weird Stuff
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What methods have you tried to address this?
What if anything has been successful for you?
Have you ever been hypnotized before?
Yes
No
If yes, what reason was the reason for the hypnosis?
What is your 1 month goal regarding this issue?
What is your 1 year goal regarding this issue?
What is your 5 year goal regarding this issue?
Please List up to Seven Benefits of Making the Change You Want
1.
2.
3.
4.
5.
6.
7.
MEDICAL DISCLAIMER
Health Questions
If applicable, please provide a list of all medications you are currently taking, and the reason for taking them:
If applicable, please provide the name(s) of your doctor(s) and /or therapist(s), as well as the reason you are seeing them:
Have you been treated for:
Heart Condition
Diabetes
Epilepsy
Pain
None of the above
Please share any medical history you think I should know about.
Do you give Hoosier Hypnosis permission to contact your doctor(s) or therapist(s)?
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Yes
No
Client Bill of Rights
Insurance
Theoretical Approach
Your Process Is Confidential
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