print form		 NY Hypnosis and Laser Center
 Intake Interview Form

Confidentiality: When received, all information on this questionnaire will be kept strictly confidential.

Submit this form OnLine to speed the processing of information.
On completion, click on the <Submit> button at the bottom of the form.


Identifying Data
Name
Number and Street
City
State
Zip
Date of Birth
 
Format as: Mo/Da/YYRR
Gender

Male

Female
  
Occupation
Daytime Phone Evening Phone
E-mail (required)

Submit e-mail address which you would like us to use to contact you.
Cell Phone

Family Information
Marital Status
Married:      Single:     Widowed/Widower:     Divorced:
Spouse Name
Children
Format: Type in Names and Ages of Children. Marital Status (if appropriate)
Grandchildren
Format: Type in Names and Ages of Grandchildren. Marital Status (if appropriate)
Siblings
Format: Type in Names and Ages of Siblings. Marital Status (if appropriate)
Parents
Format: Type in Names and Ages of Parents. Marital Status (if appropriate)
Pets
Format: Type in Names and Breeds of pets

About you
1. List three Favorite Places
2. List Fears or Phobias
3. List any compulsive tendencies
4. List current health problems
5. List all medications you are now using
6. List your three most important lifetime goals
7. List your three past-time/hobbies
8. What is your current occupation?
9. Do you enjoy your work? What do you enjoy about It?
10. List things you like to do. Are there any you would like to do better?
11. If you could be, do, have or become anything — what would you wish for?
12. Why are you seeking Hypnosis?
13. How did you hear about this office?

14. What is your Favorite Number (from 1 to 9)?
15. Name your three Favorite Colors.

Instructions: Please check off characteristics that relate to your behavior.
Visual
Auditory
Kinesthetic
1v. Likes to keep written records.
1a. Prefers having other person read instructions to put a model together.
1k. Likes to build things
                                  
2v. Typically reads billboards while driving 2a. Reviews for a test by reading notes aloud 2k. Uses sense of touch to put a model together
3v. Puts model together correctly using written directions. 3a. Talks aloud while working a math problem. 3k. Can distinguish items by touch when blindfolded
4v. Follows written recipe easily when cooking. 4a. Prefers listening to a CD over reading a book 4k. Learns touch system rapidly when typing
5v. Writes on napkins in restaurants. 5a. Commits zip code to memory by repeating it 5k. Moves with music
6v. Can build a bicycle with only written directions 6a. Uses rhyming words to remember names 6k. Doodles & draws on any available paper
7v. Review for a test by writing a summary a7. Plans the upcoming week by talking with someone 7k. An outdoors person
8v. Commits a zip code to memory by writing it. 8a. Talks to self 8k. Moves easily, coordinated
9v. Uses visual image to remember names 9a. Prefers oral directions from employer 9k. Spends large amount of time on crafts
10v. A bookworm 10a. Stops at a service station for directions 10k. Likes to feel texture of clothes & furniture
11v. Plans the upcoming week by making a list. 11a. Prefers talk/listening games 11k. Prefers action activities
12v. Prefers written directions from employer 12a. Keeps up news by listening to the radio. 12k. Finds it very easy to keep fit physically
13v. Prefers to get a map & find own way in strange city 13a. Able to concentrate deeply on what another is saying 13k. Fastest in the group to learn a new physical skill
14v. Prefers games like Scrabble 14a. Uses free time while talking with others 14k. Uses free time for physical activities

 
   

© 2003 NY Hypnosis & Laser Center
4160 S. Ft. Apache Road-Ste B
(within Madame Et Monsieur)
Las Vegas, NV 89147

Tel: 702-454-7910  Fax: 702-507-2335