CLIENT ASSESSMENT FORM Questions with * are required fields.
CLIENT INFORMATION First Name * Last Name*
E‐mail * Phone Number * (+ area code)
Yes: No:_ Date of Birth Gender Marital Status Children in home
Street Address City State Zip
EMERGENCY CONTACT
First Name * Last Name*
Relationship Phone Number
How did you hear about Redesigned Mind TM?
REDESIGNED MIND TM Hypnotherapy
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Have you received hypnotherapy services before? (If yes, please share the reason for service.) Do you have any reservations, fears or doubts about hypnosis or do you have any belief you cannot be hypnotized? PRESENTING ISSUE INFORMATION Why are you seeking hypnotherapy services and what specifically about your situation or issue is leading you to seek hypnotherapy? What other types of therapies or approaches have you tried that did and didn’t work?
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When was the first time you remember the situation or issue occurring? How did the situation or issue begin?
What other circumstances were going on at the time it began?
Iƻǿ Řƻ ȅƻdz ƪƴƻǿ ȅƻdzϥNJŜ ŜȄLJŜNJƛŜƴŎƛƴƎ ǘƘŜ ƛǎǎdzŜ ƻNJ ǎƛǘdzŀǘƛƻƴ ŀƴŘ ŘŜǎŎNJƛōŜ ǿƘŀǘ ƘŀLJLJŜƴǎ ǿƘŜƴ ƛǘ ƻŎŎdzNJǎΚ ό{ƘŀNJŜ ǿƘŀǘ ȅƻdz ǎŜŜΣ ƘŜŀNJΣ ŦŜŜƭΣ ƴƻǘƛŎŜ ƛƴ ȅƻdzNJ ōƻŘȅΣ ŜƳƻǘƛƻƴǎΣ ŜǘŎΦύ
REDESIGNED MIND TM Hypnotherapy
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What would you rather experience when faced with this situation? Describe what the desired state would be like or feel like? (What is it like, how do you feel, what do you see, any changes in the physical body, etc.) Why have you decided to make this change now? ²Ƙȅ ƘŀǾŜƴϥǘ ȅƻdz ōŜŜƴ ŀōƭŜ ǘƻ ŀŎƘƛŜǾŜ ǘƘƛǎ LJNJƛƻNJ ǘƻ ƴƻǿΚ Iƻǿ ǿƛƭƭ ȅƻdzNJ ƭƛŦŜ ƛƳLJNJƻǾŜ ǿƘŜƴ ȅƻdz ƳŀƪŜ ǘƘƛǎ ŎƘŀƴƎŜ ǘƻŘŀȅΚ
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²Ƙŀǘ ƛǎ ȅƻdzNJ м ƳƻƴǘƘ Ǝƻŀƭ NJŜƎŀNJŘƛƴƎ ǘƘƛǎ ƛǎǎdzŜόǎύΚ What is ȅour 6 month goal regarding this issue(s)? What is your 1 year goal regarding this issue(s)?
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LIFE ECOLOGY EVALUATION Please rate your satisfaction of life in each of the areas below:
Overall Health ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Weight ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Emotional Stress ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Work Related Stress ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Finances ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Sleep ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Career ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Relationships ☐ Satisfied ☐ Somewhat Satisfied ☐ Somewhat Dissatisfied ☐ Dissatisfied
Do you associate any of these emotions with your presenting issue?
☐ Stress ☐ Fears ☐ Anxiety ☐ Phobias
☐ Shame ☐ Sadness ☐ Low self‐esteem ☐ Embarrassment
☐ Boredom ☐ Loneliness ☐ Abandonment ☐ Frustration
☐ Lack of confidence ☐ Lack of motivation ☐ Lack of self‐assurance ☐ Lack of commitment
☐ Low satisfaction ☐ Negative self‐talk ☐ Lack of self‐value ☐ Depression
☐ Lack of follow thru ☐ Lack of concentration ☐ Procrastination ☐ Unmet goals
☐ Loss ☐ Grief ☐ Shame
☐ Undesirable habits ☐ Reduced performance ☐ Inability to form positive habits or behaviors
☐ Other
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Have you ever been/currently diagnosed with a mental health condition or taking/have taken a medication related to anxiety or mental health? Please describe: Do you give the Hypnotherapist permission to contact your doctor(s) and/or therapist(s) if a medical referral is needed? A referral would not be obtained without Client discussion and approval.
☐ Yes ☐ No (If the Hypnotherapist believes the presenting issue requires a medical referral, services after the initial visit will not be provided without one.) I hereby declare that the preceding statements and details provided in this assessment are true and I have not suppressed or misstated any material facts, and agree that this declaration shall be the basis of the service between me (the Client, signatory) and the hypnotherapist. Client Signature Date