Clinical Interview Intake Form - Hagerstown Hypnosis Center

Date:

Time:

:

Name:

First Middle Last

Address:

Preferred Contact Telephone:

Email:

Date of Birth:

Age

Gender

Male
Female

What do you want to accomplish with hypnosis today?

Specify:

Prior Experience with hypnosis:

None
Have been hypnotized at a stage show
Have been hypnotized one on one
Have listened to hypnosis tapes or CD’s
Have read books on hypnosis
Have friends/family who have been hypnotized

What are your beliefs about hypnosis?

I think it can help me
I will try it and see what happens
I am a skeptic

What are your three biggest personal strengths?

1)

2)

3)

HEALTH: List all medical and mental health conditions for which you are currently being treated.

1) Diagnosis:

Treating physician:

Medications:

2) Diagnosis:

Treating physician:

Medications:

3) Diagnosis:

Treating physician:

Medications:

4) Diagnosis:

Treating physician:

Medications:

List any other health concerns, fears, or issues:

List any other medications:

How much do you currently weigh?

What is your target weight?

Do you drink alcohol?

Never
Once a month
Once a week
A few times a week
Daily

Do you smoke cigarettes?

Never have
Former smoker
Yes, I am a light smoker
Yes, I am a heavy smoker

If so, When did you quit:

If so, How many cigarettes per day:

Your age when you started smoking?

Do you use marijuana?

NO
YES

If so, How often:

Do you_________________ use other drugs?

frequently
occasionally

Do you use other drugs?

Cocaine or other stimulants
Ecstasy or club drugs
Heroin or Methadone
Non-prescribed pain pills
Prescription pain pills
Prescription anti-anxiety medications (such as Valium or Xanax)
Non-prescribed anti-anxiety medications
Other drugs

Specify:

Do you have sleep difficulties?

Rarely
I don’t get enough sleep
I have trouble falling asleep
I have trouble staying asleep
I sleep too much

Eating Patterns:

I am on a special diet
I eat mostly healthy foods
I don’t eat regularly
I overeat
I do not eat enough
I binge eat
I purge myself when full
I snack too often

Specify:

Exercise Patterns:

I work out frequently
I exercise occasionally
I do not get enough exercise
I have a health condition that limits my ability to exercise

Specify:

In my personal relationships, I am:

Unsatisfied
Sometimes satisfied
Mostly satisfied
I am very happy with my relationships with others

What do you do to handle tension and stress?

What do you do for fun?

What are your hobbies?

What do you want to accomplish with hypnosis?

Comments

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