Confidential HistoryPlease complete this confidential history fully or download and print the form and bring to your appointment. Download Form Name * First Name Last Name Email * Message * Text Phone (###) ### #### Phone 1 (###) ### #### Phone 2 (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Age Date of Birth MM DD YYYY Marital Status Single Married Divorced In a relationship Recently broke up First name of person in relationship Education High School College Post Graduate Left-handed Right-handed Reason for this visit How long have you experienced it? Have you seen anyone for this problem? What type of practice? Fill in any applicable symptoms, systems Anxiety Arthritis Auto-Immune Asthma Cancer Depression Diabetes Digestive Epilepsy Fatigue Headaches Heart disease High Blood Press Infertility Insomnia Osteoporosis PMS Skin problems Stress Thyroid disease Other Explanation of other I take the following medications and or supplements: Antibiotics Heart medicine Laxatives Vitamins Anti-depressants Chemotherapy Pain relievers Insulin Blood thinners Sleeping pills Sedatives Other The following are part of my life to a high degree: Don’t skip this part! Alcohol Strongly Disagree Disagree Neutral Agree Strongly Agree Sugar Strongly Disagree Disagree Neutral Agree Strongly Agree Caffeine Strongly Disagree Disagree Neutral Agree Strongly Agree Exercise Strongly Disagree Disagree Neutral Agree Strongly Agree Nicotine Strongly Disagree Disagree Neutral Agree Strongly Agree Fun Strongly Disagree Disagree Neutral Agree Strongly Agree Stress Meditation Strongly Disagree Disagree Neutral Agree Strongly Agree Are you familiar with Hypnosis? Please describe any incidents in your past that could affect how you feel or function today? Religious or spiritual practice? Yes No Do you enjoy your work? Yes No What kind of vacations do you enjoy? Are you afraid of heights? Yes No Are you afraid of roller coasters? Yes No Are you afraid of water? Yes No Other fears? Public speaking, sales call reluctance, meeting new people Do you tend to over analyze? Yes No Do you procrastinate? Yes No Do you think you could be sabotaging your relationships or efforts at success or happiness? Yes No What behavior do you engage in that’s detrimental to you? For those seeking help with addictive disorders, please complete honestly. WEIGHT LOSS When do you first eat each day? Are you a night feeder? Yes No What foods do you snack on? What activities are you involved in when you snack? What other foods do you enjoy? Do you eat... In your car? At your desk? While watching TV? What rooms of the house are you most likely to eat in? Are you self conscious about how much you eat when eating with others? Yes No Do you consume alcohol when you are eating? Yes No SMOKING Do you want to quit? or does someone else want you to? Why do you want to quit smoking? Are you a “secret smoker” or do you smoke around other people? How long have you been smoking? How many packs a day? What time do you have your first cigarette of the day? What time do you have your first cigarette of the day? Do you smoke when you drink coffee? Do you smoke when you drink alcohol? What activities do you engage in when you smoke? Do you smoke when walking the dog? What places do you smoke in? Example: car, deck, a bar etc ALCOHOL What led you come to see me for drinking? Do you feel you drink too much? Yes No How many glasses of wine do you drink a day/week? How many drinks a day/week? How many beers a day/week? Why do you drink? Choose one To relax? To feel better? To fall asleep more easily? Do you smoke when you drink? Yes No Do you drink with most evening meals? Yes No Where are you when you drink? An individual is charged for each session. I allow 50 minutes for a session. However, I invest additional time for therapy preparation time for each session, that the individual is not charged for. My prep time might run from 10 minutes to an hour or more. I invest this extra time because I am committed to the success of the individual’s program. An individual needs to be as committed to the success of their therapy as I am! An individual has two options when paying for their sessions. They can pay for each session individually or they can save by purchasing a package of sessions. This also indicates a commitment on the individual’s part. However, I am unable to guarantee anyone’s behavior. Take weight loss for instance. If one continues to eat as they were eating when they walked in my door – they will not lose weight! Also, if one doesn’t come weekly and doesn’t keep a food diary or listen to their recording once or twice a day – they will not lose weight! Despite the language below that states no refund – occasionally there are those who don’t follow the program, but still ask for a refund. See below. The undersigned requests Lori Harber, Hypnotherapist, to provide hypnotherapy and or self-help education services. The undersigned, understands that they are responsible for all charges they incur through working with Lori Harber requires effort on the individual’s part. As I cannot guarantee that an individual will make the effort necessary to make behavioral change, there will be no refunds beyond the first session. The undersigned agrees to give at least 24 hours advance notice when canceling an appointment. Failure to do so requires payment for that appointment time. First Name Last Name If you choose to send this form, please be aware that it may not be a secure environment. You can also print the form above and bring it to your appointment. Thank you!
