Hypnosis Intake Questionaire

 

 

 

Please answer the below form as completely as you can as it relates to your therapy. If a question does not relate to you, or your condition / therapy please leave it blank.

 

Step 1: Please fill out qeustionaire below as accurately as possible.

 

Step 2: Read and accept our release statement

 

 

 

 

Your name
Email Address
Phone Number
Your Address	Address
List your most relaxing color
•  Describe a location you find relaxing / calming (e.g. beach, hiking)
•  List any fears/phobias you have (e.g. Heights, Falling)
•  Do you suffer from any compulsive tendencies? If so, please describe:
•  Please list your goal by using Hypnosis
Are you stressed? If so please list your stress level from 1 to 10	1 2 3 4 5 6 7 8 9 10
If stressed, what causes it?
Does stress or outside influences contribute to your condition	Yes, stress contributes No stess does not contribute
Do you have family / friends support in accomplishing your goals	Yes I have a support structure No, im on my own
Why are you seeking Hypnotherapy
•  Are you currently suffering from any of the following? (Please check all that apply.)	nervousness inability to relax sleeplessness depression sexual dysfunction compulsive tendencies nail biting teeth grinding nightmares poor health cigarette smoking alcohol abuse drug abuse compulsive overeating serious eating disorder codependency inability to focus attention poor memory marital problems recent divorce war trauma current illness death of a loved one childhood trauma fear of heights lack of energy poor self-esteem abusive home situation abusive work situation lack of success sexual abuse other:
•  Please describe any other conditions in your life that are negatively affecting you:
•     Please list three reasons you would like to change today?
•  Please list any positive feelings / reasons associated with your condition
Have you tried to change / stop / modify your behavior	Yes No
•  Please list methods used, and if you were successful.
Have you been Hypnotized before:	Yes No
Please describe your experience
•  Do you have any fears of being hypnotized? If so please describe
•  What would your perfect outcome from your Hypnosis session be?
Visual: Please X off characteristics that relate to your behavior.   (Hold Control downto select multiple choices)	Likes to keep written records Reads billboards while driving Uses written directons easily Uses recipes while cooking Writes on napkins or notes Review tests by writng summary Recalls numbesr by writing them Uses visual images to recall names A Bookwork Plans week by creating lists Prefers written directions Prefers maps to instructions Prefers reading / writing
Audio: Please X off characteristics that relate to your behavior.   (Hold Control downto select multiple choices)	Enjoys audio books Learns by reading aloud Talks aloud during math problems Prefers listening over reading Memorizes number out loud Talks to self Prefers oral instructions Oral directions over maps Likes oral / listening games Gets news by radio or TV Able to listen to other people easily Very talkative
Kinesthetic: Please X off characteristics that relate to your behavior.   (Hold Control downto select multiple choices)	Likes buidling things Is hands on learns by doing Can describe item by feal Outdoors Person Has to have items described Spends times on crafts Prefers active activities Learns slower without hands on Learns fast in a group
Please supply any additional information about your situation that you think we will find relevant.
Electronic signature
I have read and ACCEPT the Valleywide Hypnosis Release Statement	Yes

 

 

 

 

Release Statement

 

Please read this statement and submit your digital signature and acceptance below. This form will have to be submitted before a session is conducted

 

 

 

RELEASE STATEMENT: I hereby authorize Valleywide Hypnosis PLLC hypnotize me for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability and desire to affect change in myself. I understand that because the results of my sessions depend greatly upon my own serious participation that Valleywide Hypnosis PLLC cannot offer any guarantee of the success of my treatment. I am aware, however, that Valleywide Hypnosis PLLC will do everything in their power to ensure my success.

 

I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen hypnotherapy at this time.

 

Notice: AS THE STATE OF (Arizona) HAS NOT ADOPTED EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM, THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY.

 

Hypnotism is a self-regulating profession and its practitioners are not licensed by state governments. I am not a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are by a client, the client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse hypnotism services at any time. A client has a right to be free of physical, verbal or sexual abuse. A client has a right to know the expected duration of sessions, and may assert any right without retaliation.

 

Disclosure of Services

 

Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives.

 

Services consist of a program of conditioning, including an undetermined number of private sessions, depending on the client's individual needs. The hypnotist will to the best of his or her ability endeavor to accomplish the objectives of the client's sessions. While hypnosis may be an effective technique for many purposes, the effectiveness may vary from individual to individual, and no specific results or progress can be promised or guaranteed.

During hypnotherapy sessions, clients remain completely aware of everything that is going on. In fact, many people experience a hyper-awareness where sensations are perceived enriched and vivid. The ability to visualize or imagine is enhanced. Deep relaxation is common. Many describe the hypnotic state as a complete and total escape from physical tension and emotional stress, while remaining completely alert.

 

The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client.

While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy.

 

Contact Information : My name is Sean Gately I can be contacted through my office 6730 E. McDowell Road Scottsdale Arizona or by telephone at 877.469.4427

Education and Training: I was trained in hypnotism (or “hypnotherapy” ) at the state approved Hypnosis Motivational Institute, which is accredited by the accredited council for continuing education and training in Tarzana California, and I do annual continuing education to maintain my training at a high level.

 

 

 

 

 

 

 

 

 

 

 

 

 

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