Last Name

First Name

Gender

Male

Female

Patient Age

Date of birth

Patient Occupation

Address

City

State

Postal code

Phone *

Email *

Occupation:

If the patient is under 18 years of age, enter guardian information below.

Guardian Phone

Guardian Name

Relationship to Patient

Emergency Contact

Emergency Contact Phone Number

Please list 7 benefits of making this change in your life:

Describe any previous efforts to resolve this issue:

Have you ever done hypnosis?

Yes

If so, when?

Do you feel it was a successful hypnosis?

Do you feel you are easily hypnotized?

Yes

Do you feel you have an analytical or non-analytical mind?

Analytical

Non-analytical mind

Do you have any specific phobias? please list

Have you been in treatment with a Doctor/Therapist/Practictioner for this issue?

Do you have seizures?

Yes

Please list any medications you are taking:

Do you have any allergies? please name:

Do you have sleep issues?

Yes

Are you currently being treated for your insomnia or had any sleep studies?

Yes

Do you have any medical issues we should know about?

What do you do to relax?

Do you meditate?

Yes

How often?

Do you do yoga?

Yes

How often? (Yoga)

Do you excerise, how often and what types?

If you were to close your eyes, could you visualize a scene if described to you?

Yes

Do you consider yourself a:

Visual Learner

Auditory Learner

Kinesthetic (Feeling) Learner

Type Option 4

Additional Information

What to Expect in your Transform Now Hypnosis Sessions:

The hypnosis process takes from 50-70 minutes, approximately. It depends on the individual. It requires guiding you to a relaxed, comfortable place within yourself, using a series of relaxing breathing & visualization techniques, starting with what is known as “induction” and then various “deepeners” moving you directly into the subconscious mind where you are given hypnotic suggestions to help you to achieve your goals; you are fully aware and in control of your session at all times.

I hereby authorize Vanessa Wawrzynowicz CHT to hypnotize me for the purposes outlined in this intake form. I understand that the success of my hypnosis sessions depends greatly on my own ability to relax and desire to create change in myself. I understand that because the results of my sessions depend in part upon my own serious participation, that Vanessa Wawrzynowicz CHT cannot offer any guarantee of the success of my treatment. I am aware however, that Vanessa Wawrzynowicz CHT will do everything reasonably in her power to ensure my success. Client acknowledges understanding this questionnaire, and all information provided is accurate and complete to the best of the client’s knowledge and that hypnosis is a healing modality working alongside, not instead of medical care.

Date

Signature

Clear