Client Intake Form

Fill this up to save you time for your first session!

Please fill up the form below, providing as much relevant information as necessary. This is important for the first session, and to save you time. Rest assured, the information you provide will be kept strictly confidential. Payment option is at the bottom of the page. You can pay ahead of time, however, this form should be filled up and submitted at least 48 hours before the session. Submitting it earlier is recommended! For inquiries, please use the Contact Us Form.

Personal Details

First Name*

Last Name*


Date of Birth*

Phone Number*


Street Address

Address Line 2

City State

Postal Code

Background Details

Are you currently on any medication
 Yes No

Have you ever had hypnotherapy before?
 Yes No

Are you a smoker?
 Yes No

Describe your alcohol consumption

Describe your quality of sleep*

Have you suffered from any of the following?*
 Anxiety Depression Schizophrenia Bipolar Chronic Insomnia Phobias Addictions Compulsive disorders Drug abuse Eating disorders Other

Do you suffer from any of the following?*

What is it that you expect we can help you with (select all that apply)?*

Additional details about the problem, if any

Describe any hobbies you have or what you like doing in your spare time*

How did you find out about us?

Preferred method of contact*

I recognise that I am seeking alternative/non-medical treatment that may not be supported or endorsed by established medical practice.*

Book and pay for your first session and get your first 30 minutes free!

Simply select our secure payment option below and you’ll be directed to our payment screen.  Your payment details will be totally secured and encrypted.

Session Options