Pre-Session Intake Form

Your answers help me prepare and ensure we make the most of our time together. This takes about 5 minutes. All responses are strictly confidential.

Contact Information

Full Name*

Are you 18 or older?*

Email Address*

Phone Number

Approximate Appointment Date

Your Challenge

Primary Challenge*

On a scale of 0 to 10, with 10 being unbearable, what do you rate this Primary Challenge?*

Describe your challenge in your own words*

How long have you been dealing with this?

Background

Have you tried hypnotherapy or other therapy before?

Any relevant medical conditions or medications?

Goals and Expectations

What would a successful outcome look like for you?*

On a scale of 0 to 10, with 0 being No Longer An Issue, what is the lowest number you would find tolerable and acceptable?*

Anything else you would like me to know before our session?

How did you hear about Inner Peace Hypnosis?

I consent to the collection of this information for session preparation purposes. I understand it will be kept strictly confidential and used solely to help prepare for my hypnotherapy session.*

Your responses are confidential and protected. See our Privacy Policy.