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Bitterroot Hypnotherapy
Whitney Hedman, CHT
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Online Client Intake Form
Please take a moment to fill out the form.
First Name
Last Name
Personal Phone
Birthday
Work Phone
Email
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
I have read and agree to the following:
I have read and agree to the terms & conditions
Client Information & Terms
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