Intake Form - OptisMentis Hypnotherapy

A. Personal Information

Full Name *

Date of Birth

Gender

Marital Status

Number of Children

Email *

Phone

Address

Country

Occupation

Emergency Contact Name

Emergency Contact Phone

B. Main Concern

What is your primary reason for seeking hypnotherapy? *

Please describe your concern in more detail

Therapy Goals - what would success look like for you?

C. Lifestyle and Habits

Rate the following on a scale from 1 to 10.

Sleep Quality (1-10)

Stress Level (1-10)

Anxiety Level (1-10)

Smoking Status

Alcohol Use

D. Medical and Psychological History

Current Medications (name and dosage if known)

Medical Conditions

Psychological / Mental Health History

Do you have a history of psychosis or psychotic episodes?

Do you have a history of epilepsy or seizures?

Are you currently receiving psychiatric treatment?

Are you currently experiencing thoughts of self-harm or suicide?

F. Consent and Privacy Agreement

MindCalm Hypnotherapy provides complementary wellness and behavioral support. It is not a replacement for medical, psychological, or psychiatric care. If you are experiencing a medical or mental health emergency, contact emergency services or a licensed healthcare professional immediately.

By submitting this form you understand that:

Hypnotherapy is a complementary, non-medical service.
You remain fully in control throughout every session.
No diagnoses, cures, or medical guarantees are provided.
Your information is handled confidentially per our data privacy policy.

I understand and consent to receiving hypnotherapy services. *

I agree to the collection and processing of my personal data as outlined in the privacy policy. *

Client Intake Form

A. Personal Information

B. Main Concern

C. Lifestyle and Habits

D. Medical and Psychological History

F. Consent and Privacy Agreement