Dear Client, This "Client Intake Questionnaire" below is the first step to discovery, focus and self-healing of your challenge. Enjoy and appreciate the journey. After you book your appointment for a private hypnosis session, please return your filled out form by email to TBeersHypnosis@aol.com or by U.S. Mail to Tribeca Hypnosis & Healing Institute 60 Beach Street, Loft 5C New York, NY 10013 Kindest Regards, Trudy Beers, Certified Hypnotist
To View and/or download the form as PDF click here.
To make this easy, you can copy and past the below text into an email and send it to to TBeersHypnosis@aol.com.
Client Intake Questionnaire
CONFIDENTIALITY: When received all information on this questionnaire will be kept strictly confidential.
INSTRUCTIONS : Please fill out the following form with quick first thoughts only…Your first thought is the correct answer…Extensive description will be discussed during the session.
REMEMBER THIS IS ACTUALLY THE BEGINNING OF FINDING THE ANSWERS TO YOUR CHALLENGE …SO TAKE IT SERIOUSLY….Trudy Beers, Certified Hypnotist
Today’s Date:______________
Name:_______________________ Date of Birth:____________
Sex: _M _F
Address:_____________________________________
City__________________ State___ ZIP ____________
Occupation:_____________________________________________________
Daytime Phone:(____) _____________
Evening Phone:(____) _____________
Cell Phone: (___)__________________
E-mail:_____________________________________________
Marital Status:_____________
Name of Spouse:________________________
Name& ages of Children:_________________________________
List Three Favorite Colors:________________________________________________
1. List Three Favorite Places:______________________________
2. List any fears :
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?
Magazine :Wisdom_______NY Naturally ________NY Spirit____Internet search engine______ Google___ Referral__________________ Other__
14. Are you currently suffering from any of the following?
Please X
__ nervousness __ poor health __ poor memory__ inability to relax __ cigarette smoking __ marital problems__ sleepless__ alcohol abuse __ recent divorce__ sadness __ compulsive overeating __ current illness __ nail biting__ compulsive tendencies __ teeth grinding __ lack of energy__ nightmares __ inability to focus attention __ death of a loved one __ abusive home situation __ lack of success__ fear of heights __ other__ poor self-esteem
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. What behaviors get in the way of your happiness?
26. What would you like to start doing?
27. What would you like to stop doing?
28. What would you like to do more of?
29. What would you like to do less of?
30. What makes you laugh?
31. What makes you happy?
32. What makes you mad?
33. What makes you frightened?
34. What do you imagine yourself doing in the next 6 months?
35. What do you see or imagine yourself doing in 5 years?
36. What would have to change or be different for that to happen?
37. What are your main beliefs and values?
38. What are your main should ,could ,must and ought to’s?
39. What motivates you?
40. In one word describe your life:
41. In one word describe your problems
42. One of the things I feel proud of is:
43. Do you observe any religious or meditative practices?
44. Do you believe in past lives?
45. Please explain any other negative conditions affecting you:
46. Please list any additional needs or concerns:
Neurolinguistic Learning Channel Profile
Instructions: Please X off characteristics that relate to your behavior.
Visual:
1. Likes to keep written records [ ]
2.Typically reads billboards while driving or riding [ ]
3.Puts model together correctly using written directions [ ]
4. Follows written recipe easily when cooking [ ]
5. Writes on napkins in restaurants [ ]
6. Can put bicycle together from a mail order house using only written
directions provided [ ]
7. Review for a test by writing a summary [ ]
8. Commits a zip code to memory by writing it [ ]
9. Uses visual images to remember names [ ]
10. A bookworm [ ]
11. Plans the upcoming week by making a list [ ]
12. Prefers written directions from employer [ ]
13. Prefers to get a map and find own way in a strange city [ ]
14. Prefers reading/writing games like scrabble [ ]
Audio:
1.Prefers to have someone else read instructions when putting model
together [ ]
2.Reviews for a test by reading notes aloud or by talking to others [ ]
3.Talks aloud while working out a math problem [ ]
4. Prefers listening to CD over reading a book [ ]
5.Commits zip code to memory by repeating it [ ]
6. Uses rhyming words to remember names [ ]
7. Review for a test by writing a summary [ ]
8.Talks to self [ ]
9. Prefers oral directions from employer [ ]
10. Stops at a service station for directions in a strange city [ ]
11. Prefers talking/listening games [ ]
12. Keeps up with the news by listening to the radio [ ]
13. Able to concentrate deeply on what another is saying [ ]
14. Uses free time while talking with others [ ]
Kinesthetic:
1. Likes to build things [ ]
2.Uses sense of touch to put a model together [ ]
3. Can distinguish items by touch when blindfolded [ ]
4. Learns touch system rapidly when typing [ ]
5. Moves with the music [ ]
6. Doodles and draws on any available paper [ ]
7. An out of doors person [ ]
8. Moves easily coordinated [ ]
9. Spends large amount of time on crafts [ ]
10. Likes to feel texture of clothes and furniture [ ]
11. Prefers action activities [ ]
12. Finds it very easy to keep fit physically [ ]
13. Fastest in the group to learn a new physical skill [ ]
14. Uses free time for physical activities [ ]
Please Total each category above
Visual Number: [ ] Auditory Number [ ] Kinesthetic Number [ ]
Challenges Checklist
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. Delete those that do not apply to you..
_Need a job
_Worn out by job
_Cannot save money_long term _short term
_Cannot get ahead_Problems with co-workers or boss
_Dislike job _school
_Too much spare time_
Bad habits____________
_Weight problems:Weight:____________Height:____________Desired Weight_________
__Eat too much _sweets_junk foods_Other_________________
__Not enough exerciseGet____min. per day/week
_Dissatisfied w/appearanceWhy?____________________
__Want to quit smokingI smoke __cigaretes per day
_Difficulty getting to sleep_Cannot stay asleep
_Poor memory
_Studying is dull
_Read too slow
_Poor concentration
_Procrastinate a lot_Work _Personal
_Poor Organization
_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
_Need more goals
_Lack of skills
_Lack of motivation/ambition
_Trouble making decisions
_Lack of education classes
__Lack imagination
___Quarreling at home
_No time to relax
_Need more fun
_Unwanted emotions ________________________
__Wanted emotions that are absent:____________________
__Too pessimistic
_Legal Problems
_Fears of____________
___Afraid of people
_Low self esteem
_Fear of dying
_Too emotional
_Too nervous
_Guilt feelings
_Negative reaction to stress
_Difficulty relaxing
_Bad dreams
_Feel awkward
_Cannot express emotions(specify)______
__Dislike people
_Frequent crying
__Fear responsibility
_Quick to anger
_Too critical of others
_verbally abusive when angry
_Do not trust others
_Too sensitive
_Feel sad
_Do not communicate
_Speech problems_________
__Public speaking
_Fears
_Lack of skill
_Hearing impairment
_Cannot get up mornings
_Get sick a lot
_Fear of _health
_Aging faster than I prefer
_Desire Rejuvenation/Slow down aging
_Lack of energy
_Blood pressure _High _Low
__Physical pain_______________
__Spiritual problems
_Hard to meet people_business _personal
_Feel lonely
_Too shy
_Want a love relationship
_Desire more sex
_Unhappy marriage
_Divorce
_Relationship breakup
_Difficulty making friends
_Am not assertive_business _personal_
_ OTHER CHALLENGES ___
RELEASE STATEMENT
I hereby authorize Trudy Beers to hypnotize me for the purposes outlined in this intake form and for the future purposes that I may request. I understand that the success of my hypnosis depends greatly on my own ability and desire to affect change in myself. I understand that the results of my sessions depend greatly on my own serious participation that Trudy Beers cannot offer any guarantee of the success of my treatment. I am aware, however, that Trudy Beers will do everything in her power to ensure my success. I also understand that I have other choices from which to see assistance regarding my specific concerns, and I have chosen hypnotherapy at this time.
Signature:_____________________________- Date:_____________________
I understand that during the hypnosis session, Trudy Beers may touch me as an anchoring technique. I hereby give my permission for such touch to take place during my session.
Signature:_____________________________- Date:_____________________
Remember Hypnosis Changes Lives!!!
Certified Hypnotist, NLP Practitioner and Reiki master Trudy Beers, Ph.D. and many Tribeca Hypnosis and Healing Institute instructors are members of the National Guild of Hypnotists professional organization.