CLIENT INTAKE FORM Specialist Hypnotherapy(Robertson Health Trust) (Please complete and press SUBMIT at the end of the form) CLIENT DETAILS Client Name * First Name Last Name Client Date of Birth * MM DD YYYY Client Relationship Status * Married In a relationship Single Dependent child Parent/Guardian Name (if applicable) First Name Last Name Email * Mobile Phone * Country (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How did you find out about Specialist Hypnotherapy and/or ARFID Therapy? * HEALTH INFORMATION What is the main reason for attending this Therapy session? * Have you seen a Healthcare Professional in the past for this issue? * Yes No Not Applicable Relevant Doctor/Psychologist Name, treatment details, etc. Please list any current medications or (relevant) supplements Please list any relevant past/present medical conditions, hospital admissions or surgeries Do you consume alcohol? Never Daily Once a week Once a month Occaisionally Do you smoke? Yes No I used to smoke Do you use recreational drugs? No I have previously used I currently use Please list any additional information relevant to this Therapy session: CONSENT I confirm that the above information I have provided is true, complete and acurate. I consent to the use of hypnosis in the therapy session where the Therapist deems it appropriate. * Yes No Date form completed * MM DD YYYY Confidential Client Intake Form Robertson Health Trust (ARFID Therapy & Specialist Hypnotherapy) Thank you!Your Intake Form has been submitted and I look forward to meeting and working with you at your appointment.Warm regards…Glenn Robertson Clinical HypnotherapistARFID SpecialistSpecialist Hypnotherapy
