20. Child Intake Form Questions
1. Question: Parent/Guardian’s First Name
Why do we ask this? Your name as the parent or guardian helps us identify the primary contact for communication about your child’s therapy.
2. Question: Parent/Guardian’s Last Name
Why do we ask this? Your name as the parent or guardian helps us identify the primary contact for communication about your child’s therapy.
3. Question: Relationship to Child
Why do we ask this? Understanding your relationship to the child helps us tailor our communication and better understand the family dynamics that may influence the therapy.
4. Question: Mobile
Why do we ask this? Your phone number provides a direct method of sending your child’s session and your contact for important communications about your child’s therapy.
5. Question: Child’s First Name
Why do we ask this? Your child’s name allows us to personalize the self-hypnosis experience and maintain accurate records for their therapy.
6. Question: Child’s Last Name
Why do we ask this? Your child’s name allows us to personalize the self-hypnosis experience and maintain accurate records for their therapy.
7. Question: Parent/Guardian’s Email
Why do we ask this? Your email address allows us to send digital materials, updates, and maintain ongoing communication about your child’s self-hypnosis program.
8. Question: Child’s Date of Birth
Why do we ask this? Your child’s date of birth helps us calculate their exact age, which is crucial for tailoring the content and approach of the self-hypnosis materials to their developmental stage.
9. Question: Child’s Gender
Why do we ask this? Understanding your child’s gender helps us use appropriate pronouns and consider any gender-specific issues that might be relevant to their therapy.
10. Question: Child’s Current Year at School
Why do we ask this? Knowing your child’s school and grade level gives us context about their daily environment and academic level, which can be helpful in tailoring examples and understanding potential stressors.
11. Question: What is the primary reason you’re seeking self-hypnosis for your child?
Why do we ask this? Understanding the main issue helps us focus the self-hypnosis program on addressing your child’s specific needs.
12. Question: How long has your child been experiencing this issue?
Why do we ask this? Understanding the duration of the issue helps us focus the self-hypnosis program on addressing your child’s specific needs.
13. Question: On a scale of 1-10, how much does this issue impact your child’s daily life?
Why do we ask this? Understanding the severity of the issue’s impact helps us gauge its importance in your child’s life.
14. Question: Have you sought any other forms of treatment for this issue? If yes, please describe.
Why do we ask this? Information about previous treatments informs us about what has been tried and potentially what hasn’t worked, helping us tailor our approach more effectively.
15. Question: What have you or your child tried to address this issue?
Why do we ask this? Understanding your family’s proactivity and coping strategies helps us build on existing efforts and introduce new, complementary techniques into the self-hypnosis program.
16. Question: How do you think this issue started?
Why do we ask this? Insight into potential triggers or causes of the issue helps us address root causes and not just symptoms in the self-hypnosis materials.
17. Question: How do you imagine your child’s life would be different if this issue were resolved?
Why do we ask this? This helps us set realistic goals and understand your family’s expectations, ensuring the self-hypnosis program aligns with your desired outcomes.
18. Question: Are there any situations where the issue is better or worse?
Why do we ask this? Identifying potential triggers or alleviating factors helps us create more targeted and effective self-hypnosis strategies for your child.
19. Question: How does your child typically handle stress or difficult situations?
Why do we ask this? Understanding your child’s current coping mechanisms helps us identify areas for improvement and build on existing strengths in the self-hypnosis program.
20. Question: Does your child often worry about the future or dwell on past events?
Why do we ask this? This information indicates potential anxiety or depressive tendencies and helps us tailor the focus of the self-hypnosis materials.
21. Question: How would you describe your child’s sleep patterns?
Why do we ask this? Sleep issues can be both a cause and symptom of many problems, and addressing them can be a crucial part of the self-hypnosis program.
22. Question: Does your child have any phobias or specific fears?
Why do we ask this? Identifying specific fears helps us address them directly in the self-hypnosis materials if relevant to the main issue.
23. Question: How would you describe your child’s self-esteem?
Why do we ask this? Self-esteem often underlies many issues and affects treatment success, so understanding it helps us incorporate confidence-building elements into the program.
24. Question: Does your child find it easy or difficult to make decisions?
Why do we ask this? This indicates your child’s level of independence and confidence, helping us tailor decision-making and empowerment strategies in the self-hypnosis materials.
25. Question: How does your child typically react when things don’t go as planned?
Why do we ask this? This reveals your child’s emotional regulation abilities and resilience, allowing us to incorporate relevant coping strategies in the self-hypnosis program.
26. Question: Does your child generally feel in control, or do they feel that external factors control their experiences?
Why do we ask this? Understanding this helps us frame suggestions for empowerment and control in the self-hypnosis materials.
27. Question: How would you describe your child’s ability to focus and concentrate?
Why do we ask this? Attention issues can affect many areas of life and may need specific strategies in the self-hypnosis program.
28. Question: Does your child tend to see the positive or negative aspects of situations first?
Why do we ask this? This indicates your child’s general outlook, which can influence our treatment approach and the framing of suggestions in the self-hypnosis materials.
29. Question: How does your child typically handle criticism or negative feedback?
Why do we ask this? This reveals sensitivity levels and potential areas for building resilience, which we can address in the self-hypnosis program.
30. Question: Are there any significant past events that you believe contribute to your child’s current issue?
Why do we ask this? This helps identify potential trauma or influential experiences that may need to be addressed or considered in the self-hypnosis materials.
31. Question: How would you describe your child’s general mood on most days?
Why do we ask this? Understanding
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20. Child Intake Form Questions (continued)
Content (continued):
31. How would you describe your child’s general mood on most days?
Why do we ask this? Understanding your child’s emotional baseline helps us tailor the tone and content of the self-hypnosis materials for maximum effectiveness.
32. Does your child have any current health conditions? If yes, please list:
Why do we ask this? Medical issues can influence mental health and treatment approaches, so this information helps us ensure the self-hypnosis program is safe and appropriate for your child.
33. Is your child currently taking any medications? If yes, please list:
Why do we ask this? Some medications can interact with hypnosis or affect mental state, so this information helps us ensure the safety and effectiveness of the self-hypnosis program.
34. Please list any significant past medical conditions or surgeries:
Why do we ask this? This provides context for your child’s overall health and potential contributing factors to their current issue, helping us create a more comprehensive self-hypnosis program.
35. Is there a family history of mental health issues? If yes, please describe:
Why do we ask this? Genetic predispositions can be relevant to the treatment approach, helping us tailor the self-hypnosis program more effectively.
36. How would you describe your child’s diet?
Why do we ask this? Nutrition can significantly impact mental health and behavior, so this information may inform additional recommendations alongside the self-hypnosis program.
37. Does your child exercise regularly? If yes, what type and how often?
Why do we ask this? Physical activity levels can affect mood and overall well-being, which may influence the content and recommendations in the self-hypnosis program.
38. What are your child’s hobbies and interests?
Why do we ask this? This information can be used to personalize examples and metaphors in the self-hypnosis scripts, making them more engaging and relatable for your child.
39. What is your family’s cultural background?
Why do we ask this? Understanding your cultural background ensures cultural sensitivity in the self-hypnosis materials and approach.
40. Who lives in your household?
Why do we ask this? This provides context for your child’s home environment, which can be important in understanding their daily experiences and support system.
41. Does your child have siblings? If yes, how many and what are their ages?
Why do we ask this? Family dynamics can influence behavior and treatment success, so this information helps us understand your child’s home life better.
42. How would you describe your child’s learning style? (Visual, Auditory, Kinesthetic, or a combination)
Why do we ask this? Understanding your child’s learning style helps us tailor the delivery method of self-hypnosis materials for maximum effectiveness.
43. Has your child ever experienced hypnosis, meditation, or relaxation exercises before? If yes, please describe their experience:
Why do we ask this? This informs us whether basic education about hypnosis is needed and helps us understand your child’s familiarity with similar practices.
44. What are your expectations from self-hypnosis for your child?
Why do we ask this? Understanding your expectations helps us manage and align them with realistic outcomes, ensuring satisfaction with the self-hypnosis program.
45. What specific goals would you like your child to achieve through this therapy?
Why do we ask this? This allows us to tailor the self-hypnosis program to your child’s specific desired outcomes, making it more effective and relevant.
46. Is there anything else you think would be important for us to know about your child?
Why do we ask this? This open-ended question captures any other relevant details that might influence treatment, ensuring we have a comprehensive understanding of your child’s needs.