Download a pdf or complete the online form below

Client History Form: Please fill out the Client History Form and bring it with you to your first session. The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and as accurately as you can, you will assist me in maximizing your time and saving you money.

There are several options for filling out the client history form:

1. Microsoft Word Download of Client History Form. A MS Word version been set up so you can easily type in your responses.

If time permits, you can email your responses to me as an attachment—ideally no later than the evening before your appointment. Alternatively, you may print the form and bring it with you to your appointment. Email to Joy@JoyReichard.com.

2. PDF Download of Client History Form. You may print and complete this form and bring it with you to your first appointment.

3. If option 1 and 2 are inconvenient, you may come 30 minutes early for our first session and I will provide you with the Client History Form so you may fill it out prior to our first session.

Client Bill of Rights and Consent Form – I have provided a Client Bill of Rights and Consent Form for your review. You will be presented with this form to read and sign at the beginning of our fist session.

Download Client Rights pdf Download intake form pdf

Download Client Rights Doc Download Intake Form Doc

Hypnotherapy – 60 minute session. A more direct and focused session for achieving targeted results			Prices for packages Individual session $100.005 sessions $450.0010 sessions $850.00
Hypnotherapy/Coaching – 90 minute session. Expanded sessions facilitate a deeper exploration and resolution of issues.			Prices for packages Individual session $150.003 sessions $415.006 sessions $780.0010 sessions $1,250.00

E-mail Address: * Name: * Todays Date * Home Phone: * Cell Phone * Address * City, State, Zip * Date of Birth * Age * Gender * Male Female Marital Status * Engaged Married Re-married Separated Divorced Widowed Other Email * How did you hear about me? * Emergency Contact Phone Number What do you hope to achieve with Hypnotherapy? Medical and Health History: Have you been under a doctors care in the past year? Yes No If yes, please provide reasons Current health status List illness and injuries List hospitalization List any medications you are taking Height? Weight? Highest/lowest past weight? Indicate current and past drug and alcohol usage Have you ever had counseling or therapy? How are your sleeping patterns? If you smoke, how much? Amount of exercise? How is your diet? Background information: Current interests and hobbies? Highest level of education? Were you ever bullied? Have you ever been physically, sexually or emotionally abused? If so, please explain Family's religious/spiritual preference: Family Data: Relationship with Father Age ? Deceased? Relationship with Mother Age? Deceased? Number and Gender of Siblings Relationship with brother's/sister's Past experience with sibblings? Previous experience with siblings? Marital/Relationship History: Spouse/Parners Age Spouse/Partner's Occupation Spouse/Partner's personality (in your own words) Check areas where problems exist Children Work Arguments Friends Finances Verbal abuse Sex Substance abuse In-laws Affairs Recreation/leisure Physical abuse Communication Religious differences Other List children and ages with a short personality description of each Occupational Data: Present Job Feelings about yourself? Would you like to do something else? Yes No If so, what? Please give a short description of yourself. Any other information/concerns you would like me to know about? * Required

To learn how hypnotherapy can help you change your life, call (415) 819-8769 to schedule a complimentary 30-minute phone or in-office consultation. Or email jreich14@sbcglobal.net. Phone and virtual sessions also available!