Professional Documents
Culture Documents
Date:__________________________________
Client History
Name:_____________________________________E-mail:____________________________________
Address:_________________________________City:___________________State:_______Zip:_______
Homephone:(___)___________Workphone:(___)_________Dateofbirth:___/___/_____Age____Sex__
Maritalstatus_____________
Referral:Name:_____________________________Other:______________________________________
Hasanyoneeverattemptedtohypnotizeyou?Yes□No□Who?:____________Reason:________________
Doyoubelieveyouwerehypnotized?Yes□No□Why?:__________________________________________
Medical History
Haveyoueverbeentreatedforanemotionalproblem?Yes□No□
Ifyes,areyoucurrentlyreceivingtreatmentorcounseling?Yes□No□
Areyoucurrentlytakinganypsychiatricmedications?Yes□No□
Reasonyouarecomingforhypnosis:_______________________________________________________
Anypreviouseffortstosolveproblem?
Yes□No□Results:_______________________________________________________________________
Areyoucurrentlyundergoingmedicalorpsychologicaltreatmentfortheaboveproblem?Yes□No□
Where?:_________________________Doctor’sname________________________________________
Dohaveanyquestionsabouthypnosis?Yes□No□Whatarethey?:______________________________
____________________________________________________________________________________
Signature(Ifclientisaminoraparentorguardianmustsign)
Pleasenotethatallsessionsarerecordedforyourprotection.Theserecordsarepurelyforinternalrecord
keepingandwillneverbeusedforanyotherpurposewithoutyourexpresspermission.
IacknowledgethatIhavereceived,readandunderstandtheaboveClientBillofRights.
__________________________________________ ____________________________
Signatureofclient: Date