Client Confidential Information Form

This form is designed to prompt you to begin thinking about your life in new ways, and to give me therapeutically-relevant information about you. Whatever you write will be kept confidential. Answer each question with the first uncensored thought that springs to mind. Write as much or as little as you choose. Be sure to send the completed Form at least 2 days before your appointment. Thanks.

For added confidentiality please use a fake name. Send me an email drknight@hypnosisdepot.com to let me know the fake name you used.

Complete the Form in one go, otherwise the technology makes a mess of the submission.

Name:
Email Address:
Home/cell phone
Work phone
Date of birth
Today's date
Check appropriate box:	single married co-habiting widowed divorced
Name and age of spouse or partner
And sisters and brothers
Names and ages of children
Time zone you live in
[For NetHypnosis clients only]: Person and phone number I should call in the event of an emergency:
How did you hear about my services?
What is your main problem and when did it begin to bother you?
What do you specifically want to get from therapy?
From whom have you sought help for your problem(s)?
How is most of your free time occupied?
If employed, what kind of work do you do?
Does your current work satisfy you? If not, in what ways are you dissatisfied?
If you have hobbies, describe them here:
What are your feelings towards animals?
Check any of the following words that apply to you:	fainting spells stomach troubles palpitations dizziness anxious bowel problems no appetite fatigue angry insomnia take sedatives nightmares feel panicky use alcohol tension in conflict tremors depressed suicidal ideas take drugs unable to relax sexual problems allergies dislike weekends over ambitious shy dislike vacations feel inferior indecisive can't make friends poor memory home life bad hopeful lonely can't concentrate use painkillers fearful obsessive grateful perfectionist sad creative playful can't have fun sleep problems isolated compulsive ashamed flexible worthless bored useless deformed life is empty a nobody inadequate stupid incompetent naive guilty evil horrible thoughts intelligent morally wrong full of hate cowardly unassertive aggressive ugly unloved confused confident considerate unforgiving can't keep a job resentful sympathetic headaches
Please list other problems or difficulties here:
What physical illnesses or symptoms do you have?
When was your last medical checkup?
List medications (and doses) you are taking:
Please list your hospitalizations for physical or mental illness:
What were the important mottoes, themes, or messages you learned from your family?
How have those messages affected your self-image and your behaviour?
Describe your current relationship with your family of origin:
Describe any loss you've suffered (e.g., death of a loved one, bankruptcy, abortion, eviction)
Complete the following with the first thoughts that pop into your mind:
I am a person who
All my life
Ever since I was a child
One thing I'm proud of
It's hard for me to admit
One of the things I can't forgive
One of the things I feel guilty about
If I didn't have to worry about my image
One of the ways people hurt me
My mother was
I wish my mother
Being a woman means
Being a man means
When I look in a mirror
My spiritual/religious beliefs
As a child my spiritual/religious beliefs
My father
I wish my father
If I weren't afraid to be myself
One of the things I'm angry about
What I need and have never received from a woman
What I need and have never received from a man
The bad thing about growing up
One of the ways I could help myself
My greatest accomplishment
A person who loves me
I describe myself
Write about one or more dreams you've had at night, especially if you've had the same dream more than once:
Your signature (real or electronic) verifies that you understand "that the success of the treatment will be in direct proportion to my commitment to the end result."
I have read Dr Knight's "Hypnosis: 77 Answers to Questions I Wish You'd Stop Asking".	Yes No
I am coming to my appointment at the Westside Medical Clinic (phone is 514-489-5753) 4260 Girouard Avenue (corner Monkland) Suite 240, Montreal H4A 3C9 and will pay there, by cash or cheque. (The Clinic does not accept credit cards).
[NetHypnosis clients only] I am registering for NetHypnosis and sending $37 by:	PayPal to drknight@hypnosisdepot.com Money order to Dr Knight by mail.

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