17. Adult Intake Form Questions

1. Personal Information Section:

• What do we ask this? We ask for your full name to personalize your therapy experience and ensure we have accurate records.

2. Date of Birth:

• Why do we ask this? Your date of birth helps us understand your life experiences and tailor our approach to your age group.

3. Age:

• Why do we ask this? Knowing your age helps us better understand your life stage and experiences.

4. Gender:

• Why do we ask this? We ask about your gender to ensure we use language and examples that feel comfortable and relevant to you.

5. Address:

• Why do we ask this? Your address helps us understand your local community and any environmental factors that might be important.

6. Phone Number:

• Why do we ask this? We need your phone number to contact you about appointments or any important information related to your therapy.

7. Email:

• Why do we ask this? Your email allows us to send you appointment reminders and any helpful resources related to your therapy.

8. Occupation:

• Why do we ask this? Knowing your occupation helps us understand potential work-related stresses or satisfactions in your life.

9. Relationship Status:

• Why do we ask this? Your relationship status gives us insight into your support system and potential sources of stress or happiness.

10. Emergency Contact Name and Number:

• Why do we ask this? An emergency contact is important for your safety and well-being during our sessions.

11. What is the primary reason you’re seeking hypnotherapy?

• Why do we ask this? Understanding your main concern helps us focus our therapy on what matters most to you.

12. How long have you been experiencing this issue?

• Why do we ask this? Knowing how long you’ve been dealing with this helps us understand if it’s a recent problem or a long-term challenge.

13. On a scale of 1-10, how much does this issue impact your daily life?

• Why do we ask this? This helps us understand how seriously this issue is affecting you and how urgently we need to address it.

14. Have you sought any other forms of treatment for this issue? If yes, please describe.

• Why do we ask this? Knowing about previous treatments helps us understand what has or hasn’t worked for you in the past.

15. What have you tried on your own to address this issue?

• Why do we ask this? This shows us your problem-solving skills and helps us build on strategies you’ve already tried.

16. How do you think this issue started?

• Why do we ask this? Your perspective on how the problem began can give us valuable insights into its nature and potential solutions.

17. How do you imagine your life would be different if this issue were resolved?

• Why do we ask this? This helps us understand your goals and what success looks like to you.

18. Are there any situations where the issue is better or worse?

• Why do we ask this? Identifying triggers or relief factors helps us develop more effective strategies for you.

19. How do you typically handle stress or difficult situations?

• Why do we ask this? Understanding your coping mechanisms helps us build on your strengths and identify areas for improvement.

20. Do you often find yourself worrying about the future or dwelling on the past?

• Why do we ask this? This gives us insight into your thought patterns and helps us tailor our approach accordingly.

21. How would you describe your sleep patterns?

• Why do we ask this? Sleep can greatly affect our well-being, so understanding your sleep patterns helps us address any related issues.

22. Do you have any phobias or specific fears?

• Why do we ask this? Knowing about your fears helps us ensure our therapy approach is comfortable and effective for you.

23. How would you describe your self-esteem?

• Why do we ask this? Your self-perception can greatly influence your well-being, so this helps us understand an important aspect of your mental health.

24. Do you find it easy or difficult to make decisions?

• Why do we ask this? This gives us insight into your decision-making process, which can be relevant to many areas of life.

25. How do you typically react when things don’t go as planned?

• Why do we ask this? Your reaction to unexpected events tells us about your flexibility and stress response.

26. Do you often feel in control of your life, or do you feel that external factors control your experiences?

• Why do we ask this? This helps us understand your perspective on life events and how you view your ability to influence outcomes.

27. How would you describe your ability to focus and concentrate?

• Why do we ask this? Understanding your attention patterns helps us tailor our therapy approach and identify any related issues.

28. Do you tend to see the positive or negative aspects of situations first?

• Why do we ask this? This gives us insight into your general outlook, which can greatly influence your experiences and well-being.

29. How do you typically handle criticism or negative feedback?

• Why do we ask this? Your response to criticism can tell us about your self-image and emotional resilience.

30. Are there any significant past events that you believe contribute to your current issue?

• Why do we ask this? Past experiences can greatly influence our present, so this helps us understand important factors in your life story.

31. How would you describe your general mood on most days?

• Why do we ask this? Your overall mood gives us a baseline understanding of your emotional state.

32. Do you have any current health conditions? If yes, please list:

• Why do we ask this? Physical health can greatly affect mental well-being, so this information helps us provide safe and effective therapy.

33. Are you currently taking any medications? If yes, please list:

• Why do we ask this? Medications can interact with therapy, so this information helps us ensure our approach is safe and effective for you.

34. Please list any significant past medical conditions or surgeries:

• Why do we ask this? Past health experiences can influence current well-being, so this helps us understand your overall health journey.

35. Is there a family history of mental health issues? If yes, please describe:

• Why do we ask this? Family history can provide important context for understanding your experiences and potential genetic factors.

36. Do you use alcohol, tobacco, or other substances? If yes, please describe frequency and amount:

• Why do we ask this? Substance use can affect mental health and therapy outcomes, so this information helps us provide appropriate care.

37. How would you describe your diet?

• Why do we ask this? Diet can significantly impact mood and overall health, so this helps us understand an important aspect of your lifestyle.

38. Do you exercise regularly? If yes, what type and how often?

• Why do we ask this? Exercise habits can affect both physical and mental well-being, so this gives us insight into an important part of your routine.

39. What are your hobbies and interests?

• Why do we ask this? Knowing what you enjoy helps us understand potential sources of relaxation and fulfillment in your life.

40. What is your cultural background?

• Why do we ask this? Understanding your cultural background helps us provide respectful and culturally appropriate care.

41. Who lives in your household?

• Why do we ask this? This gives us insight into your home environment and immediate support system.

42. Do you have children? If yes, how many and what are their ages?

• Why do we ask this? Family structure can greatly influence daily life, so this helps us understand an important aspect of your personal situation.

43. How would you describe your learning style? (Visual, Auditory, Kinesthetic, or a combination)

• Why do we ask this? Understanding how you best process information helps us communicate with you more effectively during therapy.

44. Have you ever experienced hypnosis or meditation before? If yes, please describe your experience:

• Why do we ask this? Previous experiences with similar techniques can influence your expectations and comfort with hypnotherapy.

45. What are your expectations from hypnotherapy?

• Why do we ask this? Understanding your expectations helps us ensure we’re aligned in our approach and can address any misconceptions about the process.

46. What specific goals would you like to achieve through this therapy?

• Why do we ask this? Knowing your goals helps us tailor our approach to what’s most important to you.

47. Is there anything else you think would be important for your therapist to know?

• Why do we ask this? This open-ended question allows you to share any additional information you feel is relevant to your care.

48. Consent statement:

• Why do we ask this? This ensures you understand and agree to the therapy process, which is important for ethical and legal reasons.

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