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Professional hypnosis session helping a client relax and improve mindset

971-340-2020

Hypnotherapy session focused on stress relief and mental clarity

Therapeutic hypnosis session promoting personal growth and emotional balance

Home
Bio
Intake Form
Contact Me

Book a Consultation

Intake Form

Fill Out the Intake Form Before Your First Appointment

This form is to be completed before the first session:

Date *

Name *

Email *

Primary Phone *

Alternate Phone

Street Address *

City

State

Zip

Date of birth *

Age

Marital Status

Occupation

No. of Children

How did you hear about us?

Billboards/Mural

Google Search

Google Ad

Facebook

Instagram

TikTok

Media/Podcast Appearance/Interview

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

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

Results

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

Would you consider yourself a spiritual person?

Yes

Maybe

Medical History

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

Yes

If so, where?

Dr.’s name?

Have you ever been treated for emotional problems?

Yes

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

Yes

By whom?

Have you ever been treated for?

Heart

Diabetes

Epilepsy

Pain

Are you currently taking any medications?

Yes

If so, what

Reason for medication?

Have you had any prolonged illness?

Yes

If “yes”, what illness?

Have you EVER had a seizure? (responding Yes, does not disqualify you from receiving hypnosis)

Yes

Do you have any questions about hypnosis?

Yes

Sessions with Atwood Hypnosis may be 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.

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971-340-2020

Client Bill of Rights

971-340-2020

Client Bill of Rights

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