Name
*
First Name
Last Name
Email
*
Date of Birth
*
Age
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Mobile Number
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Names and Ages of Children and Spouse/Partner
How do you like to relax?
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List any fears or phobias
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Do you experience any compulsive tendencies or addictions?
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List any current health problems
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Is a doctor treating you?
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Yes
No
If yes, please give details
Have you ever been treated by the Mental Health services? Or taken anti depressants?
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Please list any particularly significant or traumatic life events
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List any prescribed or non prescribed medications you are currently taking, including alcohol, cigarettes etc…
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What is your current occupation?
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Do you enjoy your work?
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What is the emotional and psychological health of your parents?
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Do you follow a Spiritual, Religious practices or meditation? (It’s not a pre-requisite by the way!)
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Please list any other conditions occurring in your life that you believe are negatively affecting you in any way. Use as much space as you want to tell me the details of your concerns, needs or fears.
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At this moment in time, why are you seeking Hypnotherapy, Regression and/or Reiki Therapy? Please be as specific as you can (curiosity is ok but curiosity about what?)
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What previous experiences of Hypnotherapy, Regression and/or Reiki do you have?
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What would you like to achieve from this session (or sessions)?
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Depending on your session, I may wish to use a variety of different treatments, including Reiki, Energy Work and Meditation. Do I have your permission to use these in addition to Hypnotherapy and/or Regression?
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Yes
No
Is there anything else that you think I should know?
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Release Statement (terms and conditions)
*
I hereby authorise Ryan Scott to help to Hypnotise me for the purposes outlined in this intake form, and for future purposes that I may request. I understand that Hypnotherapy Therapy is not a medical procedure and that no medical benefits are being offered to me. I understand that the success of my Hypnotherapy and Regression Therapy depends on my ability to relax and my desire to create change in myself. I understand that, because the results of the sessions depend on my own serious participation, Ryan Scott cannot offer any guarantee of the success of my treatment nor am I entitled to any refund of monies paid. I am aware, however, that he will do everything reasonable in his
ability to ensure my success.
Date
*
