Ken Friberg Hypnosis - Hypnosis ... when nothing else works!
Client Intake Forms (Questionnaires)
 
 
Please Note: Most client/patients do not submit these forms as they are generally used for multiple session purposes.  Unless you are prepared to come for more than one or two sessions, it isn't necessary to fill out all of these profile forms, although they are helpful for all sessions.
 
 
Our company is based on the belief that our clients' needs are of the utmost importance. Our entire team is committed to meeting those needs. As a result, a high percentage of our business is from repeat clients and referrals.
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Every person has their own individual needs and wants.  Each person is unique.  That's why we developed a series of fun questionnaires along with a formal intake form.  Please download and print these and fill them out.  You can then either mail them, drop them off at the office or bring them with you to your initial consultation. 
 
 
 
 
 
 Profile Forms Explained
 
Intake Form:  Standard identification –name, address, phone, medical history, familiarity with hypnosis, etc.
 
7 Benefits” Form:  Everyone is asked for their personal reasons for desiring change in their life.  Although they may often seem obvious, we are all individuals and we all have our own reasons.  Stating seven benefits on paper gives us a good place to start.
 
Relaxation Profile:  Since hypnosis is completely natural, it has been found that most people have idyllic natural settings.  This form asks you to rate six calming scenes.
 
Hemispheric Brain Dominance Profile:  We all have two distinct sides or hemispheres to our brains.  The left side is more associated with logical and linear thought and generally more analytical.  The right side or “Right Mind” tends to be more creative and imaginative.  Negative emotions and avoidance behaviors are also associated with right hemisphere activities.  This form helps us determine which side of your mind is dominant so a program can be designed accordingly.
 
Hypnotic Susceptibility Personality Profile:  Some people are naturally more receptive than others to suggestion while in hypnosis.  This form allows the formation of suggestions to be more appropriate and targeted to your particular personality.
 
Neuro-Linguistic Learning Channels Profile:  We all process information in individual ways using our five senses.  This form helps us determine which paths or learning channels are most often used by you.
 
Stress Level Profile:  Since we are all subject to various stress levels, this form aids in determining your vulnerability and resiliency in everyday occurrences.
 
Smoking Trigger Profile:  Only appropriate for people desiring smoking cessation.  This form discovers a person’s reason for smoking so that we can customize a method to help one stop.
 
Overeating Trigger Profile:  Only appropriate for people desiring to change their eating habits.  Many people eat more than they really need to. It can develop into a serious health concern when a person’s eating habits are affected by influences other than a need to sustain their bodily functions and overall health.  This form helps us target an individual’s issues for overeating.
 
*Please Note:  "New Client Cover Letter" (below) mentions that several sessions may be necessary, however over 90% of our clients are positively helped with one and only one session.
 
Just click to print out the forms below:
 
 
3 Group B.doc (DOC — 142 KB)
 
 
 
 
 
Please mail them to:  Clinical Hypnosis Of New York
                                                                          33 Coventry Avenue
                                                                          Mastic, NY 11950
 
We would welcome the opportunity to earn your trust and deliver you the best service in the science of hypnosis.  We are bound by the laws of privacy (HIPPA).  Any information about you and/or your issue cannot and will not be shared or released to anyone.  We adhere to the letter of the law.  Privacy and Confidentiality are our oath.
  



 
Hours:
By Appointment Only
631-298-7260