Questionnaire for Hypnosis & Reiki Energy Work 

This form is intended to help me understand you, your present concerns, and your needs in our work together. If you have questions or if you are not clear about any of these items, put a question mark (?) in the space and please discuss it with me.

Some of these questions are personal in nature. I understand and respect if you do not wish to share information with me; if so please leave the question blank. Any question I ask is so that I can better help you.  Do know that for any information you ever share with me, confidentiality is a top priority. I will not contact your doctor or share any information with them or anyone else without your permission.

The person with whom I will be directly working with is the ONLY person who may fill-out and submit this form, unless it is a person who is unable to do so (a child, person with a disability or impairment.) This form may not show all information correctly on a mobile device or tablet. Please fill out and send via e-mail the paper version here if you must use a mobile devlce or tablet.

Name (of person who will be receiving services). Please note if a parent, caregiver, or someone else is filling out this form for another person.
Email
Have you tried any other solutions for this in the past? If so, please explain what you tried and the outcome.
Describe the primary problem or life concern that you would like help with.
Phone
How would you describe yourself as a person?
Birthday
Please list your occupation and how you feel about your current work:
With whom do you live?
Please describe your current or recent emotional state:
If your problem or concern involves other people briefly list them and their relationship to you.
Please explain your current or recent physical state, any physical complaints or concerns; and anything else related to your state of being that you think I should know:
Have you recently experienced an increase in alcohol, drug use, marijuana use, or cigarette smoking? Explain.
When was the last time you saw your physician?
Are you now or have you ever been treated for any chronic medical or psychological conditions? Please explain.
Please list the name and contact information of your primary or treating physician:
Have you ever been in psychotherapy or seen a mental health professional? If so, also list the approximate dates of treatment:
What was the primary focus of your therapy?
How helpful was it?
Do you consider yourself spiritual/religious? Please explain:
What are your sources of strength? (ex. my family, friends, strong will, creativity, logic, courage, commitment to..., spirituality or religious faith, patience, sense of humour, intelligence, perseverance, etc.)
When you are challenged or distressed by events in your life, what do you do to cope or comfort yourself?
Please help me to understand what you would like from me the most through our work together:
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much ANGER have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much ANXIETY OR FEAR have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much ENTHUSIASM OR HAPPINESS have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much ENVY/JEALOUSY have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much GUILT have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much HATRED have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much INNER PEACE/TRANQUILITY have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much JOY have you experienced?
tIn the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much LOVE have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much PRIDE have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much SADNESS/DEPRESSION have you experienced?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much SHAME/EMBARASSMENT have you experienced?
What emotions, as a child, were you taught were "good" (or were encouraged)? What emotions were you taught were "bad" (or were discouraged)? Please explain.
Do you remember your childhood experiences well? Do you remember your childhood in general?
Briefly state the first things that come to mind when thinking about your childhood experience?
What was your happy place as a child? What is your happy place now?
Do you have any fears or phobias (especially important to note for hypnosis as I will make sure to avoid any related imagery unless targeted with your permission)?
How often do you pray, meditate, or read spiritual material?
What do you do for fun?
Do you engage in social activities? Please explain.
Do you engage in any regular physical exercise or stretching? Please explain.
Do you follow any specific dietary program? How would you describe your daily eating patterns?
What hobbies or activities do you wish you could explore or pursue?
If you were free to go anywhere and do anything you want, what would you do?
In the last 90 days, on a scale from 1-5 (1 being "never" and 5 being "very often"), how much LONELINESS have you experienced?
(For hypnosis clients only) Have you ever been hypnotized before? For what? What was your experience?
(For Reiki Clients only) Have you ever received a Reiki or other energy work treatment before? For what? What was your experience or outcome?
(For all clients) What is your primary or strongest mode(s) of sensory experience? Auditory, visual, tactile?
How well can you focus? How well can you imagine?
Do you have any children and/or grandchildren? How old are they?
Are you married or in a relationship? Is this a concern?
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