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Bitterroot Hypnotherapy

Whitney Hedman, CHT

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Online Client Intake Form

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Last Name

Personal Phone

Birthday

Work Phone

Address

Occupation

Emergency Contact Name

Are you currently seeing a counselor? If yes, name of counselor? (optional)

Emergency Contact Phone

Primary Physician's Name & Phone #

Do I have permission to contact your physician?

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State a short description of your primary issue, including onset date and intervals:

Please state any previous emotional upsets, treatments, hospitalizations and medications:

State any previous or current medical problems such as heart trouble, back problems, seizure disorders, chronic pain, etc:

Check all that apply:

Childhood Issues

Fears/Phobias

Fibromyalgia

Hypertension

Improved Learning

Insomia

PTSD

Past Life Regression

Panic/Anxiety

Pain Control

Public Speaking

Self Esteem

Self Hypnosis Training

Stress Reduction

Stop Smoking

Test Anxiety

Weight Reduction

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Email: bitterroothypnotherapy@gmail.com

Phone: 406-369-2221

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