Client Intake Form
Date:
Holisticas Terapeutica Arenal
Academy of Laser and Hypnotherapy
281-860-7390
Houston Texas
CLIENT INTAKE FORM
Name: _________________________________________________
1
Today’s Date: __________________________________________________________________________
Date of Birth:____________________ Age _________ Gender: M F Race ____________________
Address: ______________________________________________________________________________
DL# :___________________________________ Employer: ____________________________________
City: ___________________________________________ State: ________________ Zip: ____________
Day Phone__________________ Home Phone: _______________Cell Phone: ______________________
E-mail:________________________________________________________________________________
Marital Status: _____Married _____Single _____Divorced _____Widow
Name of Spouse:________________________________________________________________________
Day Phone____________________ Home Phone:_______________ Cell hone:_____________________
Names and Ages of Children:
_________________________ Age ___ _________________________ Age ___
_________________________ Age ___ _________________________ Age ___
_________________________ Age ___ _________________________ Age ___
List three favorite colors: ___________________________________________________
List three favorite places: _________________________________________________________________
List any fears or phobias: _________________________________________________________________
Do you suffer any compulsive tendencies_____________________________________________________
Do you: _____ Smoke _____ Use Drugs _____ Drink Religious Preference: ________________
List any current health problems ___________________________________________________________
______________________________________________________________________________________
List any medications that you are taking:
______________________________________________________________________________________
List three of your most important life time goals_______________________________________________
______________________________________________________________________________________
List three of your past-time hobbies_________________________________________________________
Current Occupation: _____________________________________________________________________
Do you enjoy your work: _________________________________________________________________
List three things that you would like to do better or improve:
______________________________________________________________________________________
______________________________________________________________________________________
If you could be, do, have or become anything, what would you wish for?
______________________________________________________________________________________
Why are you seeking Hypnotherapy?
______________________________________________________________________________________
How did you hear about this office__________________________________________________________
______________________________________________________________________________________
Are you currently suffering from: (Select all that apply)
__nervousness __inability to relax __sleeplessness __sexual dysfunction __ nail biting __compulsive
tendencies __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 one __childhood trauma __fear of heights __poor self-esteem __abusive home
situation __abusive work situation __abusive relations of any source __ lack of success __sexual abuse
Other _________________________________________________________________________________
______________________________________________________________________________________
One of the things I feel guilty of is:
______________________________________________________________________________________
I am happiest when: _____________________________________________________________________
______________________________________________________________________________________
If I were not afraid to be myself I would _____________________________________________________
______________________________________________________________________________________
I get so angry when______________________________________________________________________
I am most saddened by ___________________________________________________________________
______________________________________________________________________________________
CLIENT INTAKE FORM
Name: _________________________________________________
All my life _____________________________________________________________________________
______________________________________________________________________________________
Ever since I was a child __________________________________________________________________
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One of the ways I could help myself but I just don’t is __________________________________________
______________________________________________________________________________________
It is hard for me to admit _________________________________________________________________
______________________________________________________________________________________
I am a person who _______________________________________________________________________
A mother should ________________________________________________________________________
A father should _________________________________________________________________________
A friend should _________________________________________________________________________
A true friend should _____________________________________________________________________
What behaviors seem to get in your way of happiness ___________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What would you like to start doing__________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What would you like to do more often_______________________________________________________
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What would you like to do less of___________________________________________________________
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What makes you laugh____________________________________________________________________
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What makes you cry_____________________________________________________________________
______________________________________________________________________________________
Do you cry a lot ______________If so how much______________________________________________
What makes you happy___________________________________________________________________
What makes you sad _____________________________________________________________________
What makes you mad_____________________________________________________________________
What makes you frightened________________________________________________________________
What do you see or imagine your life being like in 6 months to a year______________________________
______________________________________________________________________________________
______________________________________________________________________________________
What motivates you______________________________________________________________________
Who motivates you the most_______________________________________________________________
In one sentence describe your life __________________________________________________________
In one sentence describe your problems ______________________________________________________
One of the things I feel proud of is__________________________________________________________
What is the most important to you in your life_________________________________________________
What is the most important part of a relationship to you_________________________________________
Do you observe any religious or meditative practices _________Yes _________ No
Explain any other negative conditions affecting you____________________________________________
______________________________________________________________________________________
List any additional needs or concerns ________________________________________________________
______________________________________________________________________________________
Stress Level Profile:
Read each statement below and circle the number to the right of it that best represents yourself and 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 1 2 3 4
2 My decisions seem to be more impulsive than planned, I tend to feel more unsure
about my choices and often change my mind
1 2 3 4
3 The muscles in my neck, back and stomach frequently get tense. 1 2 3 4
CLIENT INTAKE FORM
Part 3
4 It seems that I have thoughts and feelings about my problems that run through my
mind most of the time
1 2 3 4
5 I have a hard time getting to sleep, and I wake up often or feel tired 1 2 3 4
6 I feel the urge to cry or get away from my problems 1 2 3 4
7 I tend to let anger build up and then explosively release my temper in some
aggressive way or destructive way
1 2 3 4
8 I have nervous habits ( tapping my fingers, shaking my leg, pulling my hair,
scratching, wringing my hands and etc)
1 2 3 4
9 I often feel fatigued, even when I have not been doing physical work 1 2 3 4
10 I have regular problems with constipation, diarrhea, upset stomach or ……. 1 2 3 4
11 I tend to not meet my expectations either because they are unrealistic or I have
taken on more than I can handle
1 2 3 4
12 I periodically lose my interest in sex 1 2 3 4
13 My anger gets aroused easily 1 2 3 4
14 I often have bad unhappy dreams or nightmares 1 2 3 4
15 I tend to spend a great deal of time worrying about things 1 2 3 4
16 My use of alcohol, coffee, smoking or use of drugs has increased 1 2 3 4
17 I feel anxious, often without any reason that I can identify 1 2 3 4
18 I conversation my speech tends to be week, rapid, broken or tense 1 2 3 4
19 I tend to be short tempered and irritable with people 1 2 3 4
20 Delays, even ordinary ones, make me fiercely impatient 1 2 3 4
RELEASE STATEMENT
I understand that Practitioners at Academy Laser and Hypnotehrapy are not a Physicians, do not practice medicine, and
do 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. Hypnosis, also referred to as
Hypnotherapy, can be used 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 or mental treatment and should
not be used as such. I understand that Hypnosis is not a replacement for my family doctors care nor is it to
be used for, or is it a replacement for any medications, diagnosis or treatment of a licensed medical doctor.
I hereby authorize to use hypnosis, Reiki, Spirtiual Counseling, EFT, Lowlight Laser Therapy or other holistic modalities that
might be found to be beneficial to 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 the practitioners at Academy Laser and Hypnotherapy
permission to use hypnosis and other modalities discussed 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 depends greatly on my
own ability and desire to affect change in myself and the results depends greatly on my own serious
participation and follow through. I understand that although hypnosis, laser and other modalities can be very effective and has a
high success rate, , does not offer a guarantee, as my own personal success
depends on my own ability and desire to create change in myself.
I understand that if I am paying by credit card that ----------------------------. will appear on
my credit card statement and that all fees for services rendered by ----------------------will be payable to
upon completion of services and is to be
paid in full. I understand that no form of insurance or state
supplied programs is offered at this time.
Signature: __________________________Date:_______________________
NOTES – COMMENTS:
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.
