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New Client Application
Full Name
Pronouns
Date of Birth
Address
Phone Number
Email
Emergency Contact (Name and Relationship to You)
Emergency Contact (Phone Number)
How did you hear about my services?
Have you been hypnotized before? If yes by whom? For what?
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?
Are you being treated for any mental health conditions? Have you ever been diagnosed or experienced symptoms of schizophrenia, psychosis, personality disorder or dissociative disorder? If yes please explain:
What would you like to accomplish through our work together?
How do you think hypnotherapy can help you?
How would you describe important aspects of your cultural identity that would be important for me to understand as your hypnotherapist?
What do you consider your greatest strengths/ sources of resilience?
Is there anything else you would like me to know?
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