First Name

Last Name

Date of birth

MM

DD

YYYY

Gender (at birth)

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Are you currently under a doctor’s care?

No

Yes

Are you currently taking any medications?

No

Yes

Do you have any medical conditions (e.g., epilepsy, heart disease, respiratory issues, psychiatric disorders)?

No

Yes

Do you have a history of mental health issues (e.g., anxiety, depression, PTSD, schizophrenia, etc.)?

No

Yes

Have you ever been diagnosed with a dissociative disorder?

No

Yes

Do you have any history of substance abuse?

No

Yes

Do you have any sleep disorders?

No

Yes

What would you like to achieve through hypnotherapy?

Stress Reduction

Anxiety Management

Smoking Cessation

Weight Loss

Pain Management

Overcoming Fears/Phobias

Confidence/Self-Esteem

Other

Have you ever been hypnotized before?

No

Yes

Do you have any concerns or fears about hypnosis?

No

Yes

Do you have difficulty relaxing or focusing?

No

Yes

Do you practice meditation or mindfulness?

No

Yes

I understand that hypnotherapy is a complementary approach and does not replace medical or psychological treatment.

I acknowledge that results vary based on individual effort, openness, and personal commitment.

I confirm that I have disclosed all relevant medical and psychological conditions.

First Name

Last Name

Date

MM

DD

YYYY