Client-Intake-Form — Modern Self

Confidential.

Please take a few moments to complete this short questionnaire which briefly touches on your previous mental health journey. If you have any questions regarding the form please do not hesitate to get in touch. I look forward to connecting with you soon.

Name

First Name

Last Name

Age

Are you seeing/recently seen (in last 12 months) any other therapist? If so, how was your experience?

Have you ever been diagnosed with a mental health condition?

Are you currently taking any medications for existing health conditions (physical or mental):

Describe your goal with hypnotherapy. How will you know when the sessions have been successful?

Do you have any fears or phobias?

Do you have any allergies?

I acknowledge that I have agreed to receiving hypnotherapy. I accept that no guarantee has been given or implied. If I have been requested to seek consent from my doctor then I have done so, or will do so.

by ticking this box i agree to these terms