Client Intake Form

	Date:
Academy of Laser and Hypnotherapy 559 Fairhope Ave. Suite 6 Fairhope, Al. 36532 251-928-8858 Navarre, Fl. 850-515-1577

This is the Intake Questionnaire we use in our office. IMPORTANT INSTRUCTIONS: Because standard Internet email is not secure enough to trust sensitive personal information we do not have this form email enabled. You must fill in the blanks then print the form to send via fax or mail. Our fax number is 251-517-4665. *CONFIDENTIALITY: When received all information on this questionnaire will be kept strictly confidential*.
Name:		Date of Birth:
	Sex: M or F
Address:
Occupation:
Daytime Phone:		Evening Phone:
E-mail:
Marital Status:		Name of Spouse:

Names & Ages of Children:
List Three Favorite Colors:
1. List Three Favorite Places:
2. List any fears or phobias:
3. Do you suffer any compulsive tendencies?
4. List any current health problems:
5. List any medications you are taking?
6. Please list your three most important lifetime goals:
7. Please list your three past-time/hobbies:
8. What is your current occupation?
9. Do you enjoy your work?
10. Please list things that you like to do but that you want to do better:
11. If you could be, do, have or become anything, what would you wish for?
12. Why are you seeking hypnotherapy?
13. How did you hear about this office?

14. Are you currently suffering from any of the following?
nervousness inability to relax sleepless depression sexual dysfunction compulsive tendencies nail biting nightmares poor health cigarette smoking alcohol abuse drug abuse compulsive overeating serious eating disorder codependency inability to focus attention	poor memory marital problems recent divorce war trauma current illness teeth grinding lack of energy death of a loved me childhood trauma fear of heights poor self-esteem abusive home situation abusive work lack of success sexual abuse other:

15.One of the things I feel guilty of is:
16. I am happiest when:
17. If I were not afraid to be myself I would:
18. I get so angry when:
19. I am most saddened by:
20. All my life:
21. Ever since I was a child:
22. One of the ways I could help myself but don't is:
23. It is hard for me to admit:
24. I am a person who:
25. A mother should:
26. A Father should:
27. A true friend should:
28. Please Mention your most significant memory, experience or event from each of the following ages:
0-5:
6-10:
11-15:
16-20:
21-25:
26-30:
31-35:
36-40:
41-45:
46-50:
51-55:
56-60:
61-65:
66-100:
29. What behaviors get in the way of your happiness?
30. What would you like to start doing?
31. What would you like to stop doing?
32. What would you like to do more of?
33. What would you like to do less of?
34. What makes you laugh?
35. What makes you cry?
36. What makes you happy?
37. What makes you sad?
38. What makes you mad?
39. What makes you frightened?
40. What do you imagine yourself doing in the next 6 months?
41. What do you see or imagine yourself doing in 5 years?
42. What would you like to be doing 5 years from now?
43. What would have to change or be different for that to happen?
44. What are your main beliefs and values?
45. What are your main should ,could ,must and ought to's?
46. What motivates you?
47. In one word describe your life:
48. In one word describe your problems:
49. In one word describe the good times in your life:
50. One of the things I feel proud of is:
51. What is most important to you in life?
52. What is most important to you in a relationship?
53. Do you observe any religious or meditative practices?
54. Do you believe in past lives?
55. Please explain any other negative conditions affecting you:
56. Please list any additional needs or concerns:

Neurolinguistic Learning Channels Profile
Instructions: Please check off characteristics that relate to your behavior.
Strong in Visual Channel	Strong in Audio Channel	Strong in Kinesthetic Channel
1. Likes to keep written records.	1. Prefers to have someone else read instructions when putting a model together	1. Likes to build things
2. Typically reads billboards while driving or riding.	2. Reviews for a test by reading notes aloud or by talking to others	2. Uses sense of touch to put a model together
3. Puts model together correctly using written directions.	3. Talks aloud while working a math problem.	3. Can distinguish items by touch when blindfolded
4. Follows written recipe easily when cooking.	4. Prefers listening to a CD over reading a book	4. Learns touch system rapidly when typing
5. Writes on napkins in restaurants.	5. Commits zip code to memory by repeating it	5. Moves with music
6. Can put a bicycle together from a mail order house using only the written directions provided.	6. Uses rhyming words to remember names	6. Doodles & draws on any available paper
7. Review for a test by writing a summary.	7. Plans the upcoming week by talking with someone	7. An out of doors person
8. Commits a zip code to memory by writing it.	8. Talks to self	8. Moves easily, coordinated
9. Uses visual image to remember names.	9. Prefers oral directions from employer	9. Spends large amount of time on crafts
10. A bookworm	10. Stops at a service station for directions in a strange city	10. Likes to feel texture of clothes & furniture
11. Plans the upcoming week by making a list.	11. Prefers talk/listening games	11. Prefers action activities
12. Prefers written directions from employer	12. Keeps up news by listening to the radio.	12. Finds it very easy to keep fit physically
13. Prefers to get a map & find own way in strange city	13. Able to concentrate deeply on what another is saying	13. Fastest in the group to learn a new physical skill
14. Prefers reading/writing games like Scrabble	14. Uses free time while talking with others	14. Uses free time for physical activities
V____	A____	K____

Stress Level Profile
Instructions: Read each statement below & circle the number to the right of it that best represents yourself & your behavior at this time.		1 - not at all 2 - slightly 3 - moderately 4 - very much
1.	I often lose my appetite or eat when I am not hungry........................	12 34
2.	My decisions seem to be more impulsive than planned, I tend you feel unsure about my choices & often change my mind.....................	12 34
3.	The muscles of my neck ,back and stomach frequently get tense......	12 34
4.	I have thoughts & feelings about my problems that run through my mind for much of the time..................................................................	12 34
5.	I have a hard time getting to sleep,wake up often or feel tired..........	12 34
6.	I feel the urge to cry or get away from my problems..........................	12 34
7.	I tend to let anger build up & then explosively release my temper in some aggressive way or destructive way...........................................	12 34
8.	I have nervous habits (tapping my fingers, shaking my leg, pulling my hair,scratching, wringing my hands & etc.)........................................	12 34
9.	I often feel fatigued, even when I have not been doing physicalwork.	12 34
10.	I have regular problems with constipation, diarrhea, upset stomach or sea.....................................................................................................	12 34
11.	I tend not to meet my expectations either because they are unrealistic or I have taken on more than I can handle......................	12 34
12.	I periodically loose my interest in sex...............................................	12 34
13.	My anger gets aroused easily............................................................	12 34
14.	I often have bad unhappy dreams or nightmares..............................	12 34
15.	I tend to spend a great deal of time worrying about things...............	12 34
16.	My use of alcohol, coffee,smoking or use of drugs has increased.....	12 34
17.	I feel anxious, often without any reason that I can identify...............	12 34
18.	In conversation my speech tends to be weak, rapid,broken, or tense.	12 34
19.	I tend to be short tempered and irritable with people........................	12 34
20.	Delays, even ordinary ones, make me fiercely impatient...................	12 34

Challenges Checklist Please place the appropriate number on the lines below on a scale of 1 to 5 ( #1 is the most important & # 5 is the least important). You may use one # more than once, for instance you may have three #1 challenges. Mark the issues that apply to you.
Need a job Worn out by job Cannot save money long term _short term Cannot get ahead Problems with co-workers employess boss Disklike job school Too much spare time Bad habits Drug problems Which drug? Drink too much How much of what? Weight problems: Weight: Height: Desired Weight Eat too much sweets junk foods Other Not enough exercise Get min. per day/week Dissatisfied w/appearance Why? Want to quit smoking I smoke cigaretes per day Difficulty getting to sleep Cannot stay asleep Poor memory used to be better for Studying is dull Read too slow Poor concentration used to be better for Procrastinate a lot Work Personal Poor Organization Time Space Would like to raise income Present income:$ /yr. desired income:$ /yr. What yr.	Desire a promotion Want to change business Jobs Work too dull Afraid to take risks business personal Blame others Want to know my life mission Nedd more goals Lack of skills Lack of motivation/ambition Trouble making decisions Lack of education willing to take classes Yes No Lack imagination Trouble with children Trouble w/loved ones________ Quarreling at home No time to relax Need more fun Unwanted emotions Wanted emotions that are absent: Depression(How often? Fear/Phobia of Afraid of people Low self esteem Thought about suicide Last time: (date) Fear of dying Too emotional Too nervous Guilt feelings Negative reaction to stress Difficulty relaxing Easily influenced Bad dreams Feel awkward Cannot express emotions (specify) Dislike people Frequent crying Different from others how?	Fear responsibility Quick to anger Too critical of others Violent_verbally abusive when angry Do not trust others Too sensitive Feel sad frequently Do not communicate Speech problems______________ Public speaking _Fears lack of skill Poor vision Wear glasses _Yes _No Desire to see well without glasses Hearing impairment Cannot get up mornings Get sick a lot Fear of _health_mental state getting worse Aging faster than I prefer Desire Rejuvenation/ Slow down aging(check one) Lack of energy I take food supplements Y/N Blood pressure High Low Menopause difficulties Allergies to Symptoms Physical pain Spiritual problems Hard to meet people business personal Still grieving over who died mo. yr. Feel lonely Too shy Want a love relationship Desire more sex Unhappy marriage Divorce Relationship breakup Difficulty making friends Am not assertive business personal Too pessimistic Legal Problems
__ OTHER CHALLENGES ______________________________________________
I understand that Robin Jones, CCHt is not a Physician, does not practice medicine, and does not diagnose or treat any medical condition. I affirm that I am not currently being treated for any medical condition related to my requested behavior modification program. Hypnotherapy can be used for as a complementary care to most medical conditions, however a referral from your physician or licensed mental health counselor is required if requesting this type of hypnosis treatment. I also understand that hypnosis is not a replacement for traditional medical treatment and should not be used as such. Signature: __________________________Date:_______________________ RELEASE STATEMENT I hereby authorize Robin E. Jones, CCHt to hypnotize me for the concerns we have discussed and/or that I have indicated on this intake form. The form is confidential and is used only as a tool in helping develop an effective program for my individual needs. I give Robin Jones, CCHt. permission to use hypnosis for any issues that have been outlined in this intake form and for any future purposes that I may request. I understand that the success of my hypnosis sessions depend greatly on my own ability and desire to affect change in myself and the results depend greatly on my own serious participation and follow through. I understand that although hypnosis can be very effective and has a high success rate, Robin Jones, does not offer a guarantee, as success greatly depends on my own ability and desire to create change in myself. I also understand that I have other Signature: __________________________Date:_______________________

Disclaimer: The information provided on this website is for educational purposes only and IS NOT intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek professional medical advice from your physician or other qualified healthcare provider with any questions you may have regarding a medical condition.

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