Name Reason you are contacting a hypnotist today Email Phone Number Date Of Birth Relationship Status - Partner's name Children's Names and Ages Two Favorite Locations/Activities Two Relaxing Pastimes Specific fears or Phobias Compulsive Tendencies ( If any ) Current or Recent Health Issues or Surgeries Other Health Professionals you are currently seeing - include contact info Are you currently experiencing any chronic discomfort? Please be specific Medications you are currently taking Medications you are currently taking Have you been hypnotized before? Have you done any meditation? Do you smoke ( tabacco, marijuana) or drink alcohol? How often? Do you exercise regularly? Be specific Do you want to lose weight? What do you see as your obstacles? Unhealthy Food Choices Portion Control Emotional Eating Stress Eating Lack of Regular Exercise Are you experiencing any of the following: Nevousness inability to relax sleeplessness depression sexual dysfunction nail biting panic attacks teeth grinding nightmares poor memory self-mutilation codependency extended greif inability to focus trauma childhood trauma low self-esteem anger management ADD lack of energy/motivation Release Statement I hereby authorize Peter Gross to hypnotize me for the purposes outlined on this intake form and for future purposes that I may agree to. I understand that the success of my hypnosis sessions depends greatly on my own ability to relax and participate actively. I understand that because the results of my sessions depend on my own motivation and ability to share my inner thoughts and feelings, Peter cannot offer any guarantees . Never the less, I understand Peter is commited do everything reasonable and within his power to ensure my success. Send