Client Information Form

The following form is to be completed by clients seeking hypnosis sessions. Your confidentiality is respected.

Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Gender*
- Male
- Female
Age*
Date of Birth*
MM slash DD slash YYYY
Occupation*
Years At Present Occupation*
Marital Status*
- Single
- Married
- Divorced
- Separated
- Widowed
- Other
Spouse's Name*
Spouse's Occupation
Children's Names and Ages:
How Many People Live In Your Household*
Church Affiliation or Preference
Have You Ever Been Divorced?*
- No
- Yes
Year(s) Divorced*
Educational Background
Years of School Completed*
Trade School / Military Service / College Degrees
Family History
Parent's Nationality
Is your father living?*
- Yes
- No
Is your mother living?*
- Yes
- No
# of Brothers
# of Sisters
Your Birth Order
Permission Consent
Physician
Physician Address
Street Address City State ZIP Code
Physician Phone
Date of Last Exam
Therapist
Therapist Address*
Street Address City State ZIP Code
Therapist Phone
Date of Last Appointment
I give my permission for Connie Madry C.M.Ht., to discuss any pertinent information with my Physician or Therapist named above.*
- I Do
- I Do Not
Medical History
Medical History
Please Check If You Have Any Of The Following Conditions:
- Allergies
- Excessive Alcohol Use
- Anorexia
- Arthritis
- Asthma
- Bulimia
- Cancer
- Crohn’s
- Drug Use
- Emphysema
- Epilepsy
- Hearing Loss
- Heart Condition
- High Blood Pressure
- Hypoglycemia
- Irritable Bowel
- Leukemia
- Thyroid Disorder
- Loss of Vision
- Low Blood Pressure
- Lupus
- M. S.
- Narcolepsy
- Sleeping Problems
- Speech Disorder
- Diabetes
- Other
Other Medical Condition*
Surgeries and Dates of Surgeries
Medications and Vitamins
Do you have any intense fears? If so please describe below:
Have you ever been in counseling of psychotherapy?*
- No
- Yes
When?*
For?*
Result?*
Have you experienced hypnosis before?*
- No
- Yes
When?*
Result?*
For?*
Hobbies?*
Favorite Time of Year*
Least Favorite Time of Year*
Describe a place that you would choose for peaceful relaxation*
Are you comfortable with elevators?*
- Yes
- No
Are you comfortable with escalators?*
- Yes
- No
List your desired hypnosis goals in order of priority:*
Referred by
- Health Provider
- Relative
- Friend
- Yellow Pages
- Ad
- Other
Please Name Referral Source
Consent and Disclaimer Form

I have been advised by Connie Madry C.Ht. for the purpose and scope of hypnotherapy and the methods of hypnotherapy to be used in my case and I give my full consent to receiving hypnotherapy sessions by the above mentioned hypnotherapist.

I understand that the results obtained through hypnosis vary with each individual and that no specific results can be guaranteed by the above mentioned hypnotherapists.

I understand that hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling.

I understand that the hypnotherapist does not treat, prescribe for or diagnosis any condition. Nothing said or done by the hypnotherapist should be construed to be such.

I also understand that the hypnotherapist is a facilitator of hypnosis and hypnotherapy and is not practicing any other profession that requires a license under the laws of the State of Michigan.

I understand that in some circumstances, such as hypnosis for glove anesthesia or pain management, it may be necessary for the hypnotherapist to respectfully touch my hand(s), wrist, arms, or shoulder(s). I hereby consent to such touching by the hypnotherapist.

I acknowledge that I am free to terminate any or all sessions at any time, and that I have agreed to participate in each session through my own consent.

I understand that confidentiality regarding my sessions will be honored between my hypnotherapist and myself. Confidentiality is also respected when working with minors or clients under the age of eighteen.

By signing below and submitting this form I hereby affirm under oath that: (1) I am 18 years of age or older; (2) I am the person identified above (or, if the person identified above is a minor, I am the parent or guardian of that person); and (3) the information provided in this form is, to the best of my knowledge, true and correct.
Client Signature*
Date*
MM slash DD slash YYYY
Parent or Guardian Signature*
If client is under the age of 18 or under the care of a guardian.
Date*
MM slash DD slash YYYY
Newsletter
Add me to the hypnotherapy newsletter list.
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Email
This field is for validation purposes and should be left unchanged.

Client Information Form

Educational Background

Family History

Permission Consent

Medical History

Consent and Disclaimer Form