Name

First Name

Last Name

Date of Birth

YYYY

Phone

Please provide the best phone number we can reach you at.

(###)

###

####

Gender

Female

Male

Other

Prefer Not to Say

Preferred Pronouns

Have you ever been hypnotized before?

Yes

If Yes, please tell us about your experience:

Have you ever experienced energy medicine before? (Reiki, bodytalk etc.)

Yes

If Yes, please tell us about it:

Please tell us why you are here; what are you hoping to achieve within the sessions?

Please list any health concerns, diagnosed or otherwise:

Traumas that have happened in this lifetime. *Please include dates/time periods as best you can.

Trauma is personal. The first thing(s) that popped into your head as you read this are we would like to know about.

Have you had any accidents, and/or serious illnesses? *Please include dates as best you can.

Fears & Phobias:

This can include heights, bugs, the dark, social settings, and anything else that popped into your head as you thought about fears & phobias

Are you concerned with the amount of drugs/alcohol you consume?

This includes recreational drugs such as marijuana

Yes

Is a loved one concerned with your drug/alcohol use?

Yes

Do you smoke or use tobacco?

Yes

Is stress a major problem for you?

Yes

Is depression a concern for you?

Yes

Do you suffer from anxiety or panic attacks?

Yes

Do you have problems with eating or your appetite?

Yes

Do you have trouble sleeping?

Yes

Have you seen a counsellor?

Yes, currently

Yes, in the past

Was the counselling of assistance?

Yes

Unsure

Preferred Method of Communication:

Text

Phone

Cancellation Policy: A reminder for your session will be sent out the day prior to your appointment. To avoid a 50% rebooking fee, or a full charge for a no-show, we ask for at least 24 hours notice. Please ensure that your sessions are put into your phone calendar with additional reminders if you need them. Submitting this form is accepting the terms of our cancelation and payment policy.

Thank you for filling out this form. This information will assist the practitioner to tailor your session appropriately. By signing this health record, you agree that you have provided this information voluntarily and are undertaking hypnotherapy and/or Energy medicine with this office voluntarily. You agree to release this practitioner from all liability and will not hold the practitioner responsible in any way for outcomes resulting from methods, instructions and programs used in the course of your treatment. Results are individual and not guaranteed. This questionnaire will be held in the strictest of confidence. Your privacy is important to us.

Date

YYYY

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Yes Please!

No Thank You.

Lily Amarais Coaching