14. Adult Intake Form

Content:

This document provides an example of the Adult Initial Intake Form used by Norwest Wellbeing. It’s designed to give you a comprehensive overview of the information we collect during the intake process for adult hypnotherapy services.

Purpose of this Example:

1. To familiarize you with the types of questions asked in our intake process.
2. To help you prepare the information you might need when filling out the actual form.
3. To demonstrate our holistic approach to understanding your needs and tailoring our therapy services.

Please note:

• This is a sample form and not for actual submission.
• The actual form will be provided to you directly when you’re ready to begin the intake process.
• All questions are carefully chosen to help us provide the most effective and personalized hypnotherapy experience for you.

Now, let’s break down the form into its sections:

1. Personal Information

Description: This section collects basic details about you to ensure accurate records and personalized communication.

• First Name
• Last Name
• Email
• Mobile Number
• Date of Birth
• Gender
• Relationship Status
• Occupation

2. Presenting Issue

Description: This section focuses on understanding the primary reason you’re seeking hypnotherapy and its impact on your life.

• Presenting Issue (description)
• Duration of the issue
• Impact level (scale 1-10)
• Previous treatments
• Self-help methods tried
• Thoughts on issue origin
• Anticipated life changes if resolved
• Situations where the issue varies

3. Psychological Patterns

Description: This section helps us understand how you typically think, feel, and react in various situations.

• Stress handling methods
• Tendency to worry about future/past
• Sleep patterns
• Phobias or specific fears
• Self-esteem description
• Decision-making ease/difficulty
• Reaction to unexpected events
• Feelings of control in life
• Focus and concentration ability
• Tendency towards positive/negative perspective
• Handling of criticism or negative feedback
• Significant past events contributing to the current issue
• General mood description

4. Medical and Health Information

Description: This section gathers important health-related information to ensure safe and effective therapy.

• Current health conditions
• Current medications
• Past medical conditions or surgeries
• Family history of mental health issues
• Substance use (alcohol, tobacco, other)
• Diet description
• Exercise habits

5. Personal Background

Description: This section helps us understand more about your life context, interests, and family situation.

• Hobbies and interests
• Cultural background
• Household members
• Number of children (if any)

6. Learning and Experience

Description: This section helps us understand your learning style and any previous experiences with hypnosis or similar relaxation techniques.

• Learning style description
• Previous experience with hypnosis or meditation

7. Therapy Goals and Expectations

Description: This final section is crucial in helping us understand what you hope to achieve through hypnotherapy.

• Expectations from hypnotherapy
• Specific goals for therapy
• Additional important information for the therapist

8. Terms and Conditions

Description: This section ensures that you have read and agreed to our policies.

• Terms and Conditions agreement checkbox