check

Hypnotherapy Intake Form

 Welcome — I’m so glad you’re here.

Thank you for saying yes to yourself and choosing this path of transformation. This intake form is your space to share what’s on your heart and mind — no pressure to have it all figured out. The more you’re able to share, the more I can tailor our sessions to meet you exactly where you are and where you want to go.

Everything you share here is held in confidence, with care and compassion. Take your time, and know that your healing journey has already begun.

Let’s begin — together, with hope.

Click the button below to start.

Start

Question 1 of 14

Hi! What is your name?

Please include preferred name if different.

Question 2 of 14

What inspired you to reach out for hypnotherapy at this time? Please be as open as possible.

Question 3 of 14

What are 1–3 changes or goals you’d love to see as a result of our work together?

Question 4 of 14

Have you done any other personal development work or healing modalities (e.g. therapy, coaching, energy work)?

Question 5 of 14

On a scale from 1–10, how would you currently rate your overall wellbeing (emotional, physical, and mental)?

Question 6 of 14

Are you currently experiencing any stress, anxiety, depression, or chronic pain? (Please describe.)

Question 7 of 14

Are you currently under the care of a therapist, doctor, or psychiatrist? If yes, please share what for. Note: certain medical topics may be out of scope, but it's very simple to get a doctor's note to ensure we're good to work together!

Question 8 of 14

Are you currently taking any medications? If yes, please list them and their purpose.

Question 9 of 14

What are some beliefs you find yourself repeating about yourself, others, your situation, or the world?

Question 10 of 14

When you’re feeling overwhelmed or stuck, what tends to happen in your body or mind?

Question 11 of 14

Are there any habits, behaviors, or thought patterns you’d like support shifting?

Question 12 of 14

Are there any topics that feel sensitive or off-limits right now?

Question 13 of 14

What helps you feel safe, grounded, or supported when things feel hard?

Question 14 of 14

Is there anything else you’d like me to know before we begin our work together?

Confirm and Submit