Intake Form Stacie Ford, Certified Professional Hypnotist stacie@elevateyourmindhypnosis.com Intake Form Today's Date First Name Last Name Email Phone/Mobile AddressAddress Line 1 City State Zip Code Date of Birth Age Gender Male Female OtherAre you currently working with: Mental Health Professional Primary Care Physician Other Health Care Provider Not applicableWhat main topic/subject will we be working on? Check all other topics that apply. Fears/Phobias Anxiety/Stress PTSD Weight Management Issues Professionally Diagnosed Eating Disorder Smoking/Tobacco or Vape Domestic Violence Stuttering Low Confidence/Self-Esteem Uncontrolled Anger Self Sabotage Negative emotional self-beliefs OCD ADD/ADHD Hoarding Low motivation Lack of time-management Loss of a loved one - unresolved grief Career/Business Enhancement Personal Development Trauma Other None of the aboveWhat else would you like to work on? Do you think hypnosis will help you? 100% yes! Not sure It's my last hope Not reallyWhat is your prior experience with hypnosis? None Have been hypnotized at a stage show Have been hypnotized one on one Have listened to hypnosis Cd’s or MP3’s Have read books on hypnosis Have friends/family who have been hypnotizedAre you currently addicted to any of the following? Not applicable Marijuana Other drugs Shopping Gambling Food/eatingWhat do you do to handle tension and stress? Emergency Contact InformationName of Emergency Contact Phone # of Emergency Contact Hypnosis techniques are not in any way meant as a substitute for standard medical, psychiatric, or psychological treatment. Any changes to your current treatment should always be monitored by your physician. I also further-note, I am not a licensed medical or mental facilitator and should not be seen as being such. If you are under a physician's care or guidance, a written statement from that provider acknowledging my involvement with you, thru hypnosis, will need to be given and kept in your file, along with contact methods of that provider, in case of an emergency. Falsifying such information or failure to provide the proper forms will result in refusal of any and all sessions. Additionally, if you are receiving an audio recording, do not listen to that in a vehicle, or while operating machinery or power tools of any kind.Signature Sign Here Submit Form
