Client Intake Form

Please fully complete and sign the below form. This form must be completed and submitted at least two days prior to your appointment.

The information on this form will assist Joyce in preparing for your session. Your time and attention spent in thoughtfully answering the questions is greatly appreciated!

General Information

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Full Name *

Phone Number *

Date of Birth *

Email Address *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How did you hear about Joyce at A Spirit Freed?

Personal Information

In order to prepare for your session, please provide the information below. All personal information will be kept strictly confidential. If a question does not pertain to you, simply fill in "N/A".

Reason(s) for seeking hypnotherapy/reiki services

Please tell me about the issues or challenges for which you are seeking assistance.

What is your motivation for making these changes now?

What would healing these issues look like to you?

What have you tried in the past to heal these issues?

Important Relationships

Please list the important relationships in your life including immediate family, spouse or partner, children, and close friends or co-workers that could come up in your session. Include first names, relationship, and ages.

Personal Beliefs & Practices

Please briefly tell me about your current personal spiritual or religious beliefs. If you were to try to connect to a power outside of yourself, who would it be? Do you have any current personal practices such as meditation, prayer, affirmations, etc.?

Life Purpose/Personal Goals

What do you feel is your life's purpose? Please list the personal goals that are most important to you.

Do you have any fears or phobias?

General Health Information

Please provide the following general health information. All personal health information will be kept strictly confidential.

Medical Conditions

Do you have any medical conditions or health issues of which I need to be aware?

Body Part Issues

Do you have any weak or vulnerable areas of your body? Do you have any areas of chronic pain or inflammation?

Emotional/Mental Issues

Please tell me about any current or past emotional or mental issues such as depression, anxiety, ADHD, etc. Do you have any current or past addictions? Have you experienced any traumatic events? Have you ever been in any type of abusive relationship?

Stress

What tends to bring you stress? What do you do when you feel stress? In what part of your body do you hold stress?

Additional Comments, Requests, or Information

Do you have any additional comments, requests or information that you think I need to know?

Consent & Agreement

I understand that spiritual hypnosis and reiki are practices for self-exploration, stress reduction, relaxation, and/or behavioral change. This may enable me to search for meaning and understanding and to direct my own personal growth and development. I further understand that all hypnosis is self-hypnosis.

I understand that I am in total control of the hypnotic state and session, and that I can end the session at any time. I understand that hypnotherapy can involve techniques such as progressive relaxation, meditation, guided imagery, as well as other methods. I understand that these methods encourage clients to recall events, circumstances, behaviors, thoughts, and feelings from prior situations in their life experience.

I understand that clients vary greatly in their response to the relaxation and hypnotic process, with some clients having powerful experiences and others experiencing relatively little. I am aware that the experiences during hypnosis may be a combination of real and/or imagined events. I also understand that certain memories or experiences may invoke emotional reactions. These emotionally charged experiences are often times useful for facilitating insight and understanding, however, they can be emotionally challenging for some clients.

I understand that I choose the goals for my hypnotherapy sessions as well as the topics for discussion while in the hypnotic state. I understand that hypnotherapy is not offered as a substitute for medical or psychological diagnosis and care. I understand that, while Joyce may offer guidance where asked, I am responsible for my own well-being and decision making. I also understand that I am responsible for my own interpretations of and reactions to the information presented to me, and for any and all decisions I make related to the information received in hypnosis.

I understand there are some conditions for which hypnosis may not be a good fit for the client. These conditions include but are not limited to: schizophrenia, pathological personalities, psychosis (including substance induced), senility, dementia, brain trauma, cognitive deficiencies, epilepsy, narcolepsy, bi-polar syndrome, clinical depression, suicidal tendencies, serious heart conditions, extremely high or low blood pressure, the elderly or frail, substance abuse, and/or currently taking medication or substances that cause drowsiness. I understand that if I am, in any way, unsure if hypnosis would be a good fit for me, that it is best to consult my medical doctor prior to participating in hypnosis. Also, if pregnant, I will also consult my medical doctor prior to participating in hypnosis.

After reading and understanding all of the above information, I am consenting to enter into hypnotherapy and/or reiki energy therapy with Joyce Nash-Ewen of A Spirit Freed LLC of my own free will and out of the desire for self-exploration and personal development. I understand that with my electronic signature, I am accepting full responsibility for monitoring my health for this and any future hypnosis sessions, and should any of the aforementioned conditions arise, I agree that I will consult my medical provider before participating in hypnosis and/or reiki therapy.

Signature *

Date *