Confidential Intake Form - Take the First Step Today

Well done taking the first step toward positive change in your life.

It will take you some time to think about these questions. So, be sure you make time for it (30 minutes would be a good start). It is all about your specialist subject matter, that being you! There are no wrong answers.

All boxes with a red asterisk are required information. However we have kept these to a minimum for you.

Name *

First

Last

What name do you prefer to be called?

Address *

Town or City *

Postcode *

Email *

Telephone *

Privacy: Is it OK to leave messages on this number?

Privacy: Does anyone else ever answer this telephone number?

Date of Birth?

26/11/1973 (Day/Month/Full Year) Please enter you D.O.B. similar to this example.

G.P. / Medical practice name & address: *

Some health issues can affect the specific therapy approach that can be most effective for you. Have you had any type of talking or psychological therapy before (e.g. hypnotherapy, NLP, counselling, psychotherapy)? *

If Yes, what type of talking therapy and what for?

Have you have ever had any suicidal thoughts or tried to harm yourself? *

If yes has this been in the last 6 months?

Have you ever been diagnosed with: (please tick all applicable boxes) *

psychosis
personality disorder
learning difficulty
type 1 diabetes
type 2 diabetes
epilepsy
any eating disorder
any other long term health issue
none of the above

Details of any of your health conditions ticked above.

Do you have any fears/phobias? (heights, water etc) *

If Yes, details of exactly what your fears / phobias are.

Are you taking any prescription or non-prescription medication? *

If Yes, what medications, how much, how often and for what health issues?

Do you have any history of trauma in your life? (any kind of abuse, neglect, victim of natural or other disaster etc) *

If Yes, please describe your trauma.

Onto nicer things now. Please describe your Family situation / Support network.

Who is there around you that supports you especially in times of need? Who can you rely on to help when you need it?

What is your occupation?

What hobbies and interests do you enjoy?

Please describe in detail your favourite, happy, peaceful place where you really can relax. It could be inside or outside, real or imaginary. Perhaps somewhere you went on holiday?

During hypnotherapy we will use your own words to describe your peaceful place. This is so you have a relaxing, peaceful, calm haven to go to that you remember vividly during your treatment. Please describe your peaceful place using the memories from your senses. What did you see, hear, feel, smell in your peaceful place? It could be inside or outside, perhaps somewhere you went on holiday?

Lifestyle questions: How good is your diet? (1 worst - 10 best)

Selected Value: 5

How good is your exercise regime? (1 worst - 10 best)

Selected Value: 5

How good is your sleep pattern? (1 worst - 10 best)

Selected Value: 5

What is your stress and / or anxiety level right now? (1 worst - 10 best)

Selected Value: 5

How many (if any) cigarettes or cigars do you smoke a day?

Selected Value: 0

Approximately how many (if any) units of alcohol do you drink a day?

Selected Value: 0

2 units = 1 Pint of lower-strength lager/beer/cider (568ml, ABV 3.6%) <->1.5 units = 1 Small glass of red/white/rosé wine (125ml, ABV 12%) <-> 1 unit = spirits (gin, rum, vodka etc) 1 single / small shot (25ml, ABV 40%) according to the NHS website.

Please describe any significant events you have had in your life over the last 12 months.

This might include a child moving out, changing jobs, retirement, a bereavement or having a child etc. Anything significant that has affected you more than just a bit.

Specific Positive Goals of Your Therapy - What would you like hypnotherapy to help you with?

Goals of therapy – What would you like hypnotherapy to do for you? What are the issues you would like hypnotherapy to help you with? Make sure it is something that you do want and not something you don't want. (e.g. I want to worry less about how my anxiety will feel tomorrow - rather than - I don't want anxiety)

What needs to change positively to meet your goals?

Establish what needs to change positively for you - (What needs to be different? What do you need to achieve to make the change?

Imagine you wake up one day and the change has happened. How would you know that it happened? How would things be different? Re-imagine the future when you have achieved your goal.

Re-imagine the future when you goal has been met. What will it be like when your goal is met? Try to imagine using your dominant senses. What will you see/feel/hear/smell/taste?

How motivated are you about changing positively and hypnotherapy helping you do so?

Selected Value: 0

GDPR required questions. I have read the privacy policy and agree Relaxing Hypnotherapy can use my personal information for the following purposes. (Please tick all applicable boxes indicating agreement for each use). You can withdraw any of these permissions any time. Please just let us know in writing. *

- to deliver therapy to me.
- to reply to any of my queries by phone, text or email.
- to contact me between my therapy appointments should the need arise.
- to collect any payments due, to maintain records and keep accounts.

A filled or partially filled reply to this form online or by email is considered as full consent to the above.