Intake Form | Portland, Oregon

This form is to be completed at the initial session:

Please fill out this side of the form and read the Client Bill of Rights on the reverse side.

Signing this form indicates that you have read that information.

Date

Name

Home Phone

Work Phone

Address

City

State

Zip

Date of birth

Age

Sex

Marital Status

Occupation

No. of Children

How did you hear about us?

Yellow Pages

Newspaper

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

No

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

No

Results

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

Would you consider yourself a spiritual person?

Yes

No

Maybe

Field label

Medical History

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

Yes

No

If so, where?

Dr.’s name?

Have you ever been treated for emotional problems?

Yes

No

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

Yes

No

By whom?

Have you ever been treated for?

Heart

Diabetes

Epilepsy

Pain

Are you currently taking any medications?

Yes

No

If so, what

Reason for medication?

Have you had any prolonged illness?

Yes

No

If “yes”, what illness?

Do you have any questions about hypnosis?

Yes

No

Sessions at Atwood Hypnosis are video taped, and become part of your confidential record.

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.

Client Signature

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*Parent/Guardian Signature (Signature is required if client is under 18 years old)

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

Fill Out the Intake Form Before Your First Appointment