Ascension Hypnotherapy & Wellness

CLIENT INTAKE FORM

This form gathers foundational information for your clinical hypnotherapy plan. Please answer honestly and completely.

Demographics

Full Name	__________________________________
Date of Birth	____________
Phone	____________
Email	____________
Address	__________________________________

Primary Concerns

What are your main reasons for seeking hypnotherapy at this time?

Symptom Checklist

Check any that apply:

[ ] Anxiety
[ ] Depression
[ ] Sleep issues
[ ] Chronic pain
[ ] Addictions
[ ] Trauma/PTSD
[ ] Anger
[ ] Grief
[ ] Self-esteem issues
[ ] Relationship challenges
[ ] Other: _____________

Substance Use

Describe any alcohol, drug, or medication use (past or present):

Spiritual or Energetic History

Include any belief systems, energetic sensitivities, or intuitive practices:

Consent

I affirm that I am voluntarily seeking hypnotherapy. I understand my practitioner is not a medical doctor or psychologist. I am responsible for my own healing journey.

Signature: ____________________________ Date: ____________