Name:
Email:
Phone Number:
Physical Address:
Why are you scheduling a session(s):
Time(s) when the problem occurs:
How long has this been an issue:
When did it first occur:
What effect does it have on your daily life:
What has helped:
What has made it worse:
Do you have any experience with or reservations about hypnotherapy?
What other type of therapy/ support groups are you participating in:
How do you feel about anger, in particular yours? And have you done any anger/ rage work before:
What life patterns do you experience:
Do you have any obsessive relationships (not limited to romantic. Can include family, friends, peers, teachers,
coworkers, pets, places, etc…):
Where have you lived and considered living:
Have you had an abortion, miscarriage, still birth:
Do you feel your parents were good role models of healthy relationships:
What is your addiction(s):
Activities around the addiction that you enjoy as much as the addiction itself:
What are your fears:
Worries:
Is there anyone you have been or are close to that is an addict and you feel effected by their addiction:
How do you identify yourself:
What is your internal dialogue:
Date of Birth and Age:
Sun Sign: Moon Sign: Rising Sign: Chinese Zodiac:
Blood Type:
Birth Order:
What was your mother’s pregnancy like with you:
Comments your mother has told you about your birth, infancy and childhood:
First memory and at what age:
Are there any gaps in memory:
Any childhood trauma, neglect (including emotional), sexual abuse, stress, etc… you endured:
Were your basic needs as a child met? Including physical affection (not sexual), allowed pleasure and pain,
validation, sense of mattering, taken seriously, structure, predictability, mutual trust, creative space and support to
be different, encouragement, praise, warmth, security, healthy food, clothing, a safe place to live, medical care,
time with your parents and their attention, direction in problem solving techniques and strategies.
What were your parents limitations:
Are you going through now or have you ever gone through poverty:
Car accidents, operations, war, natural disasters:
What religion were you raised as:
What religion are you now:
Do you feel like you are able to choose freely what religion you are:
Do you pray and if so who do you pray to:
Other spiritual practice(s):
Do you meditate:
Do you allow yourself alone time with your mind:
How do you handle stress:
Where do you find relaxing at this time:
Angels, Guides, Ancestors, Deceased loved ones:
Highest level of education:
Relationship status:
Who is your support system:
Living situation:
Is your living situation safe and relaxing:
Are there any triggers at home that feed the addiction:
Present career:
Past careers:
Creative Outlet:
What do you do for fun/ What are your hobbies:
Present ailments:
Past ailments:
Anything life threatening:
Life Path/ Life’s Purpose:
What emotions are you feeling right now:
If anything were possible what would you like your life to look like right now:
How many sessions do you feel it will take to address this (usually 5- 10+):
Also note that sessions with me are in addition to other treatments especially when addressing addiction, eating
disorders, and transitioning between genders.
Anything else before we get started: