CONFIDENTIAL CLIENT QUESTIONNAIRE

NOTE: All information will be kept strictly confidential. Please be aware that the more you tell me about yourself, the more I may be of assistance to you. Please feel free to use the comment box at the bottom of this form to go into detail about anything you wish me to know.

Please be certain to fill in all fields, otherwise the questionnaire cannot be processed. If a field does not apply to you, specify N/A.


Name
Email
Date of Birth (mm/dd/yyyy)
Sex
Address
City
State
Zip Code
Day time Phone (please include area code)
Evening Phone (please include area code)
Employer
Position
Personal Status
Name and Ages of Children
Name of Spouse
 
Parents (living)
Other family information
Reason for appointment
Have you had any previous experience with hypnoisis or meditation?
No
If yes, please provide a brief explanation.
 
What other forms of therapy have you tried?
Are you currently being treated by a physician?
No

If yes, for what?

 

Primary physician
Phone number
Are you currently being treated by a psychologist/psychiatrist? 
No
   
If yes, for what?
 
Current health problems:
Fears/phobias
 
List medications you are currently taking and for what reason.

List any herbs or vitamins you regularly ingest.

Medical History - Please check all that apply.
(For multiple selections, hold down Control Key while selecting items)

If any of the above apply, please provide a brief explanation:

Are you currently experiencing any of the following: (Please check all that apply)

Do you regularly exercise? 
No
 
What do you do to relax?
 
Please list your past-times/hobbies 
 
Your favorite, most relaxing outdoor place. 
 
Referred by    friend relative co-worker  physician other  
If referred by a physician please provide name:
   
Additional Comments

RELEASE STATEMENT: I understand that the success of my hypnosis therapy depends greatly on my own ability to relax and desire to create change in myself. I also understand that because the results of my sessions depend greatly upon my own serious participation that Karen B. Reiss cannot offer any guarantee of the success of my treatment. I hereby consent to be hypnotized and release Karen B. Reiss from all liabilities and claims. I acknowlege that I have provided her with a clear and accurate mental and physical history of myself. I assume all financial responsibilities for services rendered on my behalf.
Date: Name
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