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Confidential Client History Form

Date*

Month

Day

Year

Name*

Home Phone*

Cell Phone*

Address*

City*

State

Zip*

Occupation*

No. of Childern*

How did you hear about us?*

Website

Internet/Google

Other Advertisement

Or, Referral

If so, who referred you?

If you were referred by a medical professional, do we have your permission to discuss your progress with him/her?*

Yes

Has anyone ever tried to hypnotize you?*

Reason

Do you believe that you were hypnotized?*

Why

Generally, how did it go for you?

Reason you are coming for hypnosis*

Any previous attempt to address this issue?*

Yes

Results

We find it useful to sometimes use a holistic approach (mind-body-spirit) when appropriate.

Would you consider yourself a spiritual person?*

Yes

Maybe

Medical History

Are you currently undergoing medical or psychological treatment for the above issue?*

Yes

If so, Where?

Doctor Name?

Have you been under a doctor’s care in the past year?*

Yes

If “yes”, please give reason

Dr.’s name?

Have you ever been treated for emotional problems?*

Yes

If “yes”, are you currently receiving treatment or counseling?

Yes

_ By whom?

Have you ever been treated for?*

Heart

Diabetes

Epilepsy

Pain

Are you currently taking any medications?*

Yes

If so, what

Reason for medication?

Have you had any prolonged illness?*

Yes

If “yes”, what illnes

Do you have any questions about hypnosis?*

Yes

Sessions at the Whitney Christina Hypnosis are recorded. The recordings are the property of Whitney Christina Hypnosis and are not shared with clients or anyone outside of my office. Any appointment changes need to be made two business days in advance. Appointments broken or canceled without the two business days’ notice will be charged for the session. Thank you.

Client Signature*

Parent/Guardian Signature*

(Signature is required if client is under 18 years old)

*If you wear HARD contact lenses, please remove them before your session, as they inhibit your ability to relax.