Forms | Inner Balance

Client Intake Form

CLIENT INFORMATION

Name

Age

Address

Phone

Main reason for your visit?

Relevant Medical Condition/s

Are you currently under a Physician's care for these conditions?

Yes

Current medications

Physician's name

Phone

Are you currently working with a mental health professional?

Yes

Name

Phone

Medications you are taking

Have you spoken to your doctors about hypnotherapy as an adjunct to your care?

Yes

Note: If the reason for your visit is related to a medical concern for which you are receiving treatment, it may be necessary to receive your physician or therapist's approval to use hypnotherapy as an adjunct to your medical treatment.

Any sensitivities (dark, heights, water, aromas)

Favorite Activities (hiking, reading, surfing)

Things you enjoy (sunrise, animals, places, music)

Positive experiences or successes

Relevant past challenges

Feel free to share any spiritual or religious beliefs or life philosophies that you feel are relevant?

Experiences, feelings or life style habits you would like to Cultivate ( 'exercise in nature', 'feel joy')

Client's Areas of Focus (select all that apply)

Other areas of focus

Customary Refund Policy

If you are dissatisfied with your hypnotherapy session, a full refund will be offered.

It is your right to refuse any aspect of her services and to seek the services of another provider at any time.

Jonmarie Kerns, International Board of Hypnotherapy Certification Number: FO410-035

Hypnotherapy is an educational process that facilitates access to internal resources that assist people in solving problems, increasing motivation, or altering behavior patterns to create positive change. Education and training in Hypnotherapy is classified under Human Services in the Health and Human Services Division of the Classification of Instructional Programs by the United States Dept. of Education.

Jonmarie does not practice psychotherapy or provide medical treatment. Consultation and/or referral from a licensed physician or mental health professional may be required before hypnotherapy services are provided.

Client eSignature

Date