Client and Clinical Information
Please fill out this form as best you can so we can provide you with the most relevant service.
First name
Last name/ Family Name
Email
Phone Number
Date of Birth
Gender
Emergency Contact Person Full Name
Emergency Contact Person Phone Number
Which is your preferred language?
What do you wish to accomplish/ achieve from the Hypnotherapy?
When did the symptom/s start?
When was the last time it affects you?
How does it affect you emotionally/ physically?
From a scale from 1-10 (0- not motivated; 10- extremely motivated), how motivated are you to make the change/s?
Any of your family member/s suffer the similar symptoms?
Yes
No
Maybe
Currently, do you have any medical conditions? If yes/ maybe, kindly answer next questions.
Yes
No
Maybe
Kindly describe/ explain more about it.
Currently, are you on any medication/s? If yes, kindly answer the next question.
Yes
No
Kindly describe/ explain more about it.
Do you have any fears/ phobias? If yes, kindly answer the next question.
Yes
No
Kindly describe/ explain more about it.
Have you gone through depression previously? If yes, please answer next question.
Yes
No
Kindly describe/ explain more about it.
What are your hobbies?
What is your favorite colour?
Which is your favorite place of relaxation?
Are you a smoker?
Yes
No
Do you take recreational drugs?
Yes
No
Do you consume alcohol? If Yes, please answer next question.
Yes
No
How often do you consume alcohol?
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