Intake – Leaves of Change

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Date:

Personal Information

Full Name:

yes, you you

Date of Birth:

Age:

Gender (optional):

Address

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City

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Phone Number (Cell):

Phone Number (Home/Other):

Email Address: *

Emergency Contact Information

Name:

Relationship:

Phone Number:

Health Information

1. Are you currently under the care of a medical or mental health professional?

If yes, please explain:

2. List any current medications or supplements you are taking:

3. Do you have any chronic conditions or recent health concerns?

If yes, please explain:

4. Do you have any allergies?

If yes, please list:

5. Have you experienced hypnotherapy before?

If yes, when and for what purpose?

Mental Health and Trauma History

1. Have you received any mental health diagnoses from a licensed provider?

If yes, please list the diagnosis/diagnoses:

2. Have you experienced any significant traumas in your life?

If yes, please provide a brief description:

Spiritual or Religious Orientation

1. Do you have a particular spiritual or religious orientation that is important to you?

If yes, please specify (optional):

Goals for Hypnotherapy

1. What are your main goals for seeking hypnotherapy?

2. Have you experienced any of the following? (Check all that apply)

Anxiety
Depression
Insomnia
Stress
Phobias/Fears
Chronic Pain
Weight Concerns
Smoking Cessation
Relationship Issues
Trauma or PTSD
Other (please specify):

3. Describe any additional goals or expectations you have for hypnotherapy:

Relaxation Preferences

1. Is there a color you find particularly relaxing or soothing?

2. Is there a place you find relaxing, whether real or imagined? Describe it briefly:

Lifestyle Information

1. Do you practice any wellness activities (e.g., meditation, yoga, exercise)?

If yes, please list:

2. How would you rate your current stress level?

3. Do you use any substances such as tobacco, alcohol, or recreational drugs?

If yes, please specify:

Consent, Liability Waiver, and Acknowledgment

By signing below, I consent to receive hypnotherapy services from Leaves of Change, LLC. I understand that hypnotherapy is not a substitute for medical treatment, psychological, or psychiatric services. I acknowledge that any suggestions made during sessions are for wellness purposes only and that outcomes may vary.

Liability Waiver: I hereby release Leaves of Change, LLC, its employees, and agents from any and all liability, claims, demands, actions, and causes of action related to any loss, damage, injury, or other consequences arising from or related to my participation in hypnotherapy sessions. I fully understand and agree that I am responsible for my own physical, mental, and emotional well-being during and following each session.

Client Signature:

Date:

Hypnotherapist Signature:

Date:

leaves of change: a healing arts practice

nurturing growth healing and transformation

Hypnotherapy Form

Personal Information

Emergency Contact Information

Health Information

Mental Health and Trauma History

Spiritual or Religious Orientation

Goals for Hypnotherapy

Relaxation Preferences

Lifestyle Information

Consent, Liability Waiver, and Acknowledgment

leaves of change: a healing arts practice

nurturing growth healing and transformation

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