Client Application for Hypnotherapy Name * First Name Last Name Email * Phone (###) ### #### Are you over 18? Yes No Address Address 1 Address 2 City State/Province Zip/Postal Code Country Sexual Orientation Gender Identity Name of Emergency Contact Emergency Contact: Phone (###) ### #### How did you hear about my services? Google Facebook Instagram Referral Other Referral Name First Name Last Name Have you been hypnotized before? Yes No If "Yes", by whom? Please list any prescribed medications you are taking Are you currently, or have you ever been under the care of a mental health therapist or counselor? Are you being treated for any mental health conditions? Yes No If "Yes", please explain What is your presenting issue? Is there anything else you would like me to know? Thank you!
