Minor intake form 1 | Force By Nature Hypnosis

MINOR INTAKE FORM

Child's First Name:

Child's Last Name:

Child's Date of Birth

Hypnotherapy Goals:

Is the child currently receiving any ongoing medical or psychological care? If so, explain. Please include any daily medications and/or diagnosis

Has the child ever been hypnotized before? If so, by whom?

Please describe your child’s current family structure or living arrangement: (e.g., shared custody, blended family, single-parent household, etc.)

anything else you think I might need to know?

The first step is getting started!