Intake Appraisal

Full Legal Name

Street Address

City

State

ZIP Code

Phone with area code

Date of Birth

Referred By

Current/Past Health Conditions

Prescribed Medications

Name/address of medical/mental health providers

In case we agreed to take you on as a client, do we have your consent to contact your medical/mental health providers with updates to keep them informed of your progress, to prevent possible procedures/methods that can counter your successes?

Yes

Purpose for Hypnosis

Four Specific Goals to be Achieved

Goal 1

Goal 2

Goal 3

Goal 4

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