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Astral Playdates Intake Form
Before we meet, I'd like to collect any of the following information from you that you feel comfortable sharing.
Just fill out the form below and press send.
E-mail
Name
Phone
Occupation
Employer
Date of birth
What are your preferred pronouns?
Marital status
Single
Married
Divorced
Widow(er)
Separated
Number of children
How did you hear about us?
Please fill out the name of the person who referred you to Astral Playdates
Do you have a hearing problem?
Knowing about this, I can speak more loudly if needed. If you normally wear a hearing aid, please use it as you will have your eyes closed and will not be able to lip-read during a session.
Your concerns / Your goals
Anger
Grief
Stress Management
Sleep Improvement
Motivation/Procrastination
Confidence
Relationships
Weight Management
Attitude/Outlook
Fear/Apprehension
Study Skills
Self-Esteem/Self-Image
Facilitate Wellness
Change Habit(s)
If you'd like to elaborate on any of your goals and concerns, please feel free to do so.
If yes, feel free to share a brief medical history, such as the name of your doctor and the condition.
Name of Dr. / Condition
Have you had a check-up or physical within the past year?
Yes
No
Please list any significant current or past health issues or hospitalizations
Are you in any physical pain, either intermittent or constant?
Have you been diagnosed with any of the following?
OCD (Obsessive-compulsive disorder)
Severe Clinical Depression
Schizophrenia
Bipolar or manic-depressive
Seizure disorder
Post-traumatic-stress syndrome
Parkinsons disease
Alzheimer disease or dementia
Brain injury
Diabetes
Any other medical details you would like to share?
Are you under the care of a mental health professional?
Feel free to share the name of your mental health professional and the condition you are being treated for.
Other comments or questions
Any previous experience with hypnosis?
If yes, please share some additional information. When did you have a session? What was the main goal of the hypnotherapy? Was it a group or an individual session? How did it go for you?
Any objection if I make a general reference to a higher power, a creative force, or a universal force in your session?
Please briefly share anything else that might be helpful to know about you
i.e. recent life-changing events such as deaths, divorce, relationships, job changes, health issues, trauma, accidents, etc...
Send
