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Revival Hypnotherapy

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Client Intake Form

Thank you for your interest!

You will need to complete the following questionnaire BEFORE our first introduction session is confirmed.

Your information is confidential and will not be shared.

If you wish to return to our homepage click here.

Last name(Required)

First name(Required)

Preferred name

Address(Required)

Email(Required)

Mobile No (E.g. +61411222333)(Required)

Birthday(Required)

Day

Month

Year

Gender(Required)

Male

Female

Other

Height(Required)

Weight(Required)

Have you previously received any of the following: Psychology, psychiatry, counselling, or hypnotherapy(Required)

Yes

If Yes, please provide brief details(Required)

How would you describe your current physical health?(Required)

How would you describe your current sleeping habits?(Required)

How many times per week do you exercise?(Required)

Do you have any difficulties with your appetite or eating patterns?(Required)

Yes

If Yes, can you provide a brief description of your issues?

What do you consider are your strengths?(Required)

What do you consider to be your weaknesses?(Required)

Are you currently experiencing:(Required)

Anxiety/Stress

Chronic pain

Concentration issues

Depression

Domestic violence issues

Drug dependency/use

Excessive alcohol use

Feeling overwhelmed

Grief/Loss

Obsessive behaviours

Overeating

Panic attacks

Phobias

Poor work environment

Relationship problems

Sadness

Sleep problems

Smoking addiction

Suicidal thoughts

Undereating

Do you have ADHD?

Yes

Maybe, I’m not sure

What goals are you wanting to achieve with the help of hypnotherapy?(Required)

Have you ever experienced hypnosis before?(Required)

Yes

If Yes, can you please describe your experience?

Please add anything else you would like to share with us or that you thing we should know?(Required)

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