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CONFIDENTIAL CLIENT INFORMATION

If you want to find out if Alan can help, fill out the confidential information form. When you submit the form, Alan will contact you and talk about what options you have. Always feel free to call at any time.

Name:

Age:

DOB:

Phone:

Home:

Work:

Cell:

Address:

Apt.

City:

State:

Zip:

Email address:

Occupation:

Employer:

Marital Status:

How Long:

Significant otherís name:

Children: How many:

Ages:

Names:

How did you hear about us?:
   
What is the specific problem or situation we can help you with: (Brief summary)


Note any conditions requiring your hospitalization or outpatient treatment over the last three years. Include dates.

   

Currently in treatment for:
   

List medications:
   

Have you ever been in counseling or psychotherapy? If so, how long and with what results?
   

Have you ever been hypnotized?
Was it successful?
I, the undersigned, having requested a consultation for hypnotherapy, understand that hypnotherapy is a conditioning process, whereby an individual is taught to use their own abilities, for their own lasting results. I understand that personal results vary. Further, I am aware that hypnotherapy is non-medical, and agree to consult my personal doctor for medical advice and/or treatment.

I realize that missed appointments, without 24 hours notice, will be fully chargeable to me at regular rates.

I understand that I am responsible for the results of my hypnotherapy, and that all payments, for past, current, or future sessions, are non-refundable.

I also understand that all information is strictly confidential.

Signature
Date
 
 
UNWANTED EMOTIONS
 
Depression
  
Too emotional
  
Fear mental state getting worse
  
Post traumaticstress
  
Anxiety
  
Phobia of
  
Anger
  
Quick to anger
  
Verbally abusive
  
Sadness
  
Feel sad frequently
  
Frequent crying
  
Guilt
  
Fear of
 
Fear of dying
  
Fear of flying
  
Fear of Doctor/Surgery
  
Shy
  
Too sensitive
  
Too nervous
  
Easily influenced
  
Do not trust others
  
Don't like people  
 
 
DO YOU HAVE A HISTORY OF:
 
Physical abuse
  
Family abuse
  
Sexual abuse
  
Childhood abuse
  
Suicide attempts  
 
 
HABITS
 
Want to quit smoking  

Pack(s) per Day
Drug problems - Which drug?
 
Alcohol problems - How much of what?
 
Obsessive compulsive behavior
  
Other bad habits  
 
 
PHYSICAL PAIN
 
Acute pain
Chronic Pain
Pending Surgery
  
Cancer
  
Lupus
  
Fibromyalgia
  
Childbirth  
 
 
PERSONAL
 
Cannot express emotions
  
Do not communicate well
  
Speaking problems
  
Fear responsibility
  
Get sick a lot
  
Aging faster than I prefer
  
Lack of energy
  
Cannot get up mornings
  
Lack imagination
  
Bad dreams
  
Feel awkward
  
Blood pressure
  
High Low
  
Menopause difficulties
  
Allergies
  
Symptoms
  
No time to relax
  
Need more fun
  
Grieving over someone?
  

Who
When: Month Year
 
 
DESIRED EMOTIONS THAT ARE ABSENT
 
Happiness
 
Excitement
  
Love
  
Focus
  
Confidence
  
Motivation
  
Relaxation
  
Comfort  
 
 
RELATIONSHIPS
 
Quarreling with family
  
Unhappy marriage
  
Divorce
  
Relationship breakup
  
Difficulty meeting people
Difficulty keeping friends
  
Trouble with children
  
Trouble w/loved ones
  
Sexual difficulties
 
 
PROFESSIONAL
 
Fear of public speaking
  
Desire a promotion
  
Want to change:
  
Business Job
  
Work too dull
Afraid to take risks
  
Blame others
  
Want to know my life mission
  
Need more goals
Lack of skills
  
I am not assertive
 
Sales enrichment
  
Sales phone reluctance
  
Too pessimistic
Legal problems
  
Lack organization
  
Lack communication with staff
  
Present income
Desired income
 
 
INSOMNIA
 
Difficulty getting to sleep
  
Cannot stay asleep
Sleep walking
 
 
WEIGHT
 
Weight problems:
  

Present weight

Desired weight
Eat too much:
  
Sweets
Junk foods
Not enough exercise
  
Dissatisfied w/appearance
Why?
 
 
I want to learn self- hypnosis