Inner Deep DiveHypnotherapy Intake Form Name * First Name Last Name Birth Date * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * You can optionally check the box "Sign up for news and updates" to get an email when I release new videos, host a new class, etc. May I email you? * Yes No Phone * (###) ### #### May I leave a message? * Yes No Emergency contact name * Emergency contact phone * (###) ### #### Emergency contact relationship * Referred by Occupation Place of employment Marital Status Married Single Divorced Widow/Widower Other Family/others you currently live with? Have you ever attempted suicide? Yes No Are you currently having suicidal thoughts? If yes, help is available; please call 988 Yes No Personal medical history (check all that apply) Epilepsy Diabetes Hypoglycemia Seizures Recent Head Injury Heart Trouble Pacemaker High/Low Blood Pressure Migraines Mental Illness Any other significant health concerns? Current medications and for what? What is the presenting symptom, issue or concern are you seeking help? How long has this been an issue? Under what circumstances did you first experience this problem/concern/condition? What have you done in the past that worked or did not work? Why is it important to resolve this issue now? What is stopping you from having what you want now? Childhood associations? (i.e. trauma) What/Who makes life more difficult? What are your previous experiences with hypnosis, meditation, etc.? What other forms of therapy have you tried for this issue? (Type and Duration) Length of workday, week and work style? What do you do to relax? What are your interests, how would you describe yourself? Are there any issues/habits with food? What are your sleeping habits/routine? (e.g. insomnia, sleep apnea, nightmares, frequent waking) Drug and Alcohol use (What, How Much, and How Often?) Any form of regular exercise? What are your religious/spiritual beliefs? Do you have any fears or phobias? Who supports your proposed changes? What would you say your primary sense is? (e.g. Auditory, Visual, Feel, etc) Is there anything that I haven’t asked that you feel is important for me to know? Thank you! Version: 20250216