Name First Name Last Name Date of Birth * MM DD YYYY Are you over 18? * Yes No Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### Email * What are your preferred pronouns * Emergency Contact Name and Phone Number * How did you hear about my services? Have you ever been hypnotized before? * Yes No If yes, by whom? Please list any prescribed medications you are taking * Are you currently, or have you ever been under the care of a mental health therapist or counselor? * yes no Are you being treated for any mental health conditions? * Yes No If yes, please explain What is your presenting issue? * How do you think hypnotherapy can help you? * Is there anything else you would like me to know? Type Your Signature * First Name Last Name Date MM DD YYYY Thank you!