Client Intake Form Adult English - Yoshiko Sinaga CHt, CT

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Appointment & Intake Form English

YoshikoSinaga.com

Please answer the form as honest as you can to make the session productive for you.

General Information

First Name

Last Name

Nickname

Place of BirthPlace of Birth

Date of Birth

Genderpick one!

Emaila valid email

Phone Number

Religionyour religion

Marital Statuspick one!

Ralationship Statuspick one!

Name of spouse

Number of children

Name of children

Age of children

Addressyour home address

Qualification Information

How did you know about us?pick all that apply!

SeminarReferenceInternet

You want to do therapy base on?pick all that apply!

My own wishSomeone's wishOthers

How was your relation with your father when you were young?pick one!

GoodAverageBad

How was your relation with your mother when you were young?pick one!

GoodAverageBad

Please describe 1 (one) specific problem or disease that you want to solve in this hypnotherapy session

Problem / Disease Descriptionmore details

0 /

Do you believe that you can recover from this problem/disease?pick one!

YesNo

Do you believe that this problem/disease is due to heredity?pick one!

YesNo

Has there ever been a doctor or someone you respect said that this problem/disease could not be cured or difficult to overcome?pick one!

YesNo

Have you tried to solve this problem before?pick all that apply!

HypnotherapyDoctorPsychologistPsychiatristCounsellingOthers

Describe how it was done and the resultsmore details

0 /

Have you done a hypnotherapy session before?pick one!

YesNo

Based on your current understanding, hypnotic state is a state of?pick one!

SleepRelaxed/FocusedUnconsciousOthers

Do you have concern about hypnosis and/or hypnotherapy?pick one!

YesNo

If you have concern about hypnotherapy, can you briefly explainmore details

0 /

Related with the problem you want to solve in this therapy session, please rate the intensity of your feeling from 0 to 10, toward yourself, others, or to an event(s).

0 if you feel nothing and 10 if you intensely feel this emotion and it disturbs your life! Then explain briefly about the emotion. You just need to fill the emotions that you think are relevant

Anger0 - 10 ; 0 is Normal and 10 Intense

010

Anger - Briefly explainmore details

0 /

Disappointment0 - 10 ; 0 is Normal and 10 Intense

010

Disappointment - Briefly explainmore details

0 /

Hurt0 - 10 ; 0 is Normal and 10 Intense

010

Hurt - Briefly explainmore details

0 /

Revenge0 - 10 ; 0 is Normal and 10 Intense

010

Revenge - Briefly explainmore details

0 /

Offended0 - 10 ; 0 is Normal and 10 Intense

010

Offended - Briefly explainmore details

0 /

Hate0 - 10 ; 0 is Normal and 10 Intense

010

Hate - Briefly explainmore details

0 /

Regret0 - 10 ; 0 is Normal and 10 Intense

010

Regret - Briefly explainmore details

0 /

Frustrated0 - 10 ; 0 is Normal and 10 Intense

010

Frustrated - Briefly explainmore details

0 /

Fear/Afraid0 - 10 ; 0 is Normal and 10 Intense

010

Fear/Afraid - Briefly explainmore details

0 /

Nervous/Anxious0 - 10 ; 0 is Normal and 10 Intense

010

Nervous/Anxious - Briefly explainmore details

0 /

Shame0 - 10 ; 0 is Normal and 10 Intense

010

Shame - Briefly explainmore details

0 /

Lonely0 - 10 ; 0 is Normal and 10 Intense

010

Lonely - Briefly explainmore details

0 /

Sad0 - 10 ; 0 is Normal and 10 Intense

010

Sad - Briefly explainmore details

0 /

Incapable0 - 10 ; 0 is Normal and 10 Intense

010

Incapable - Briefly explainmore details

0 /

Rejected0 - 10 ; 0 is Normal and 10 Intense

010

Rejected - Briefly explainmore details

0 /

Unworthy0 - 10 ; 0 is Normal and 10 Intense

010

Unworthy - Briefly explainmore details

0 /

Unwanted0 - 10 ; 0 is Normal and 10 Intense

010

Unwanted - Briefly explainmore details

0 /

Have you been in doctor’s treatment in the past?pick one!

YesNo

Are you currently taking prescription medication?pick one!

YesNo

Do you currently have any of the following?pick all that apply!

Heart problemAsthmaPregnancyStrokeDiabetesCerebral PalsyHypertensionHypotensionEpilepsyNone

Are you currently under a doctor or psychiatrist treatment?pick one!

YesNo

Please mark on these physical symptoms that you often havepick all that apply!

SinusitisMigraineUlcerNeck painFrozen shoulderPain upper backPain lower backMenstrual crampIrregular periodMuscle crampConstipationGastricSweaty/cold palmCold feetPain on legsSwollen feet

How do you know when you have solved your main issue/problem? How would you feel?more details

0 /

What positive change that will happen in your life when you solve your main issue/problem ?more details

0 /

Session Appointment Details

The fee for each session is Rp2.000.000, the session is approximately 2 -3 hours. Please select the available date and time to schedule the appointment and inform the therapist by WhatsApp to 08118401037 to get confirmation on the schedule.

Session Time & Datemake an appointment