NJ Hypnosis Center
YOUTH CLIENT PROFILE
Please print clearly.
Name _____________________________________ Age _______ Date ___________________
Address _______________________________ City ______________ St. ______ Zip ________
Phone: Home _________________ Work ________________ Best Time To Call ___________
Occupation _________________________________ Referred By _______________________
E-Mail Address ________________________________________________________________
Reason For Appointment ________________________________________________________
The Worst Thing About My Problem Is: _________________________________________
The Best Thing About Solving My Problem Will Be: _______________________________
Previous Efforts / Attempts For Solving The problem _________________________________
______________________________________________________________________________
ARE YOU CURRENTLY UNDER THE CARE OF A PHYSICIAN, PSYCHOLOGIST, OR COUNSELOR? Yes ___ No ___ In The Past 3 Years? Yes ___ No ___ Earlier? Yes ___ No ___
If Yes, Name __________________ What You Are/Were Being Treated For? ________________
CURRENT MEDICATIONS ________________________________________________________
YOUR PRESENT AND PAST MEDICAL HISTORY (Circle) Cancer, Heart Disease, Fainting, Headaches, Hypertension, Epilepsy, Diabetes, Asthma, Chronic Illness, Suicide Attempts, Drug/Alcohol Addiction, Thyroid, Mental Illness, Phobias, Other _________________
REMARKS:
Changes in habits or behavioral problems precipitated by hypnosis emerge from and are controlled by the subconscious mind. Many habits or behavioral problems such as, but not limited to, smoking, overeating, confidence, athletic performance, phobias, etc..., are very resistant to change. Only clients who are genuinely committed to eliminating negative habits or behaviors tend to respond to any form of intervention including hypnosis programs. Hypnosis facilitates alterations of habit and/or behavior patterns and makes the change process easier, but does not and cannot force it to occur.
RELEASE AND WAIVER by signing below, I understand and agree to the following:
(I) All client information on this form is accurate and correct.
(II) I have been fully informed, to my satisfaction, regarding hypnosis and I am aware that there is no guarantee of success.
(III) I hereby release Jack Nicholais, his heirs, personal representatives and assigns, of and from all claims and liabilities, including but not limited to, negligence, personal injury, and informed consent, in anyway relating to hypnosis or services provided by Jack Nicholais.
* Note: There will be a $25.00 charge for appointments not kept or cancelled with less than 24 hours notice. Any exceptions are based on severe illness or medical emergency and must be accompanied by a doctor’s statement.
Parents
Signature ___________________________________________ Date _____________________
HABITS AND BEHAVIORS
INSTRUCTIONS FOR FILLING OUT THIS FORM: Be as detailed and complete as possible. Your honesty will allow me to put the most effective suggestions into your sessions and will enable you to obtain the maximum positive results.
1. Do you sleep well? Y ___ N ___ Are you rested in the morning? Y ___ N ___
2. Do you get up during the night? Y ___ N ___ If yes, for what? __________________ How many times? __________
3. Time you wake up in the morning? ____
4. Do you eat breakfast? Y ___ N ___
5. Do you eat lunch? Y ___ N ___
6. Do you eat dinner? Y ___ N ___
7. Do you exercise? Y ___ N ___ What method? _________________________ How often? ______________________
8. Do you think about/or suffer from your issue while at home? Y ___ N ___
9. Do you think about/or suffer from your issue while riding in the car? Y ___ N ___
10. Do you think about/or suffer from your issue while at school? Y ___ N ___
11. Do you think about/or suffer from your issue while at play? Y ___ N ___
12. When you think about/or suffer from your issue, what is most common in your thoughts? _______________________ _________________________________________________________________________________________________
13. What will you be able to do more of after solving your issue? _____________________________________________
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14. When do you feel is your weakest control of your problem? _________________________________________________
15. What do you feel is your strongest control of your problem? ________________________________________________
16. When is your most difficult time/stressful situation because of the problem? ____________________________________
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17. What is the MOST important reason that you have decided to use hypnosis? ________________________________
18. How confident are you that hypnosis will help you? _______________
On a scale from 1-10, with 10 being the highest, rate each of the following situations
Pain ________ N/A _____ Stress ________ N/A _____
Friendships ________ N/A ____ Romance ________ N/A _____
Anger ________ N/A _____ Life Limiting ________ N/A _____
PERSONAL AND LIFESTYLE
INFORMATION
1. Rate the stress level of school from 1-10, with 10 being the highest level of stress.
REMARKS:
2. Rate the level of enjoyment and satisfaction that you experience in your life from 1-10, with 10 being the highest.
REMARKS:
3. Describe your relationship with family members, if they are stressful or negative.
REMARKS:
4. List the ages of all of your siblings and other people living in your home.
REMARKS:
5. Rate the satisfaction level of your relationship with your present parents/guardians from 1-10, w/ 10 the highest.
REMARKS:
6. If you are currently in a relationship, state how you feel about it and rate your level of personal happiness as things are now from 1-10, with 10 being the highest.
REMARKS:
7. What hobbies or recreational activities do you enjoy and/or participate in?
REMARKS:
DETAILS ABOUT YOUR PROBLEM
To maximize your positive experience with hypnosis and to make the greatest change in your life, please offer details on this page that can be directly used during your hypnosis sessions. Use more paper if necessary.
(Ex. Fear of heights – I feel anxiety when I enter a glass elevator at work, or when I enter onto an escalator at the mall. I also feel upset when I drive over large bridges, and I never go on festival/fair rides because of the heights.
Please include any significant losses or traumatic experiences with this issue in your past and/or present.
WHAT IS YOUR PROBLEM?
_______________________________________________
WHEN DOES THIS ISSUE AFFECT YOU MOST?
WHAT DO YOU WANT INSTEAD OF THIS PROBLEM?
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