What to put on a hypnotherapy intake form (with template)

A hypnotherapy intake form should collect five things: how to reach the client (and someone in an emergency), what they want help with in their own words, their health history and medications, a short set of screening questions that tell you when to slow down or refer, and their consent. Keep it to about 20 questions, send it as soon as the first session is booked, and read it before the client arrives. A full copyable template is at the end of this post.

This is practical guidance, not legal or medical advice. Hypnotherapists in most US states are not licensed health providers, so the form should help you decide when hypnosis fits and when someone else should be involved, not diagnose.

What should a hypnotherapy intake form include?

If a question doesn’t serve one of these jobs, leave it off.

Section	What it’s for	Typical questions
Contact	Reaching the client, and someone else in an emergency	Name, email, mobile, date of birth, emergency contact
Goal	What the sessions are for, in the client’s words	What would you like help with? What would a good outcome look like?
Health history	Context that changes how you work	Other conditions, primary care doctor, previous therapy
Medications	Context, and a prompt to involve their doctor	Regular medication, and any recent changes
Screening	Spotting when to pause or refer	Psychosis, seizures, heart condition, current care, thoughts of self-harm
Preferences	Shaping the script	Imagery they find relaxing, anything they dislike
Consent	Agreement to take part, signed	Treatment consent with a typed or written signature

Which contact details do you need?

Keep this short. You need:

• Full name, email and mobile number
• Pronouns (optional; useful when you write scripts)
• Date of birth. It confirms the client is an adult, and if not, tells you a parent or guardian needs to be involved (see what goes in a hypnotherapy consent form)
• Emergency contact: a name and phone number
• Primary care doctor: name and practice

Skip home address and insurance details unless you actually use them.

How should you ask about the goal?

This is the most useful part of the form, so give it the most room. Ask open questions and let the client answer in their own words:

What would you like help with?

When does it show up? Describe the last time it happened.

What would a good outcome look like for you? How would you know things had changed?

Two reasons to ask it this way. First, the words a client uses are the words your script should use. If they call it “the 3 a.m. spiral”, a suggestion that names “the 3 a.m. spiral” will land better than one about “sleep difficulties”. Second, the outcome question tells you whether their expectation is realistic. “Feel calmer before presentations” is a goal you can work toward. “Never feel anxious again” is a conversation to have in the first session.

The goal section is your script brief; see how to write a hypnosis script.

A tick-list of focus areas helps you sort clients later. Put it after the open question, not instead of it.

What health history should you ask for?

Ask enough to know who else is involved in the client’s care and whether anything changes how you work:

• Any physical or mental health conditions, past or current
• Medication taken regularly, and any started or stopped in the last few months
• Previous hypnotherapy or other therapy, and how it went
• Whether they are currently seeing a doctor, psychiatrist, psychologist or counselor for the issue they’re bringing to you

The last question matters most: if someone else is treating the same issue, you should know. For pain, also ask whether a doctor has assessed it, so hypnosis doesn’t delay a diagnosis.

Which screening questions suggest a referral?

Be honest with yourself here: the evidence on who hypnosis harms is thin. Serious harm appears to be rare. When Bollinger reviewed adverse event reports from hypnosis trials on ClinicalTrials.gov, the rate of serious adverse events likely caused by hypnosis was 0%, and other adverse events ran at 0.47%. But every one of those trials used hypnosis for medical conditions or procedures, not psychiatric conditions, and several trials reported no adverse event data at all.¹ A 2024 review of 49 meta-analyses found that safety data were reported in less than half of them.² Where problems were reported, they included a client who felt dizzy and one who stopped treatment after a panic attack during hypnosis.³

Gruzelier’s older review found adverse effects common but mostly short-lived, with more serious outcomes reported mainly in clinical and entertainment settings, including two first-episode schizophrenia cases (one after hypnotherapy, one after stage hypnosis).⁴ Wagstaff found no substantive scientific evidence of a special link between hypnosis and schizophrenia, while still urging caution.⁵ A 2025 clinical overview lists psychosis, especially schizophrenia with delusions of influence, as the main contraindication, based largely on its first author’s experience.⁶

So the standard screening questions rest mostly on clinical caution, not trial data. They are still worth asking, because each answer changes what you do next.

The questions to ask

Use plain yes/no questions with room to add detail, and tell the client why you’re asking: “A yes doesn’t rule you out. It means we’ll talk before your first session.” Ask about psychosis, schizophrenia or bipolar disorder; epilepsy or seizures; heart conditions; current mental health treatment; a recent traumatic event; thoughts of self-harm in the last month; and worrying alcohol or drug use. The exact wording is in section 4 of the template below.

What to do with a yes

• Psychosis, schizophrenia or bipolar disorder. Refer to, or work only alongside, the client’s psychiatrist or another licensed mental health professional. This is the contraindication named most often.
• Seizures. We found no good evidence that hypnosis triggers seizures. The reason to ask is practical: you need to know what a seizure looks like for this client, what to do if one happens, and whether their neurologist is aware.
• Heart condition. Again, precaution more than evidence. Ask whether their doctor knows they’re seeking hypnotherapy, and avoid deliberately intense emotional work.
• Current mental health treatment. Ask permission to coordinate with whoever is treating them.
• Recent trauma. Recent, raw trauma can come up strongly in session. Consider whether a trauma-trained licensed therapist is the better first step, and don’t go looking for the memory (see below).
• Thoughts of self-harm or suicide. Do not start hypnosis. Contact the client the same day, encourage them to see a licensed professional, and give them the 988 Suicide & Crisis Lifeline, which they can call or text at 988, around the clock.⁷
• Substance use. Ask who else is involved, and refer when it is more than you’re trained for.

What should you not ask on an intake form?

Every answer you collect is something you have to store safely and, in some states, keep for years. Leave off:

• “Do you want to recover memories?” or anything that suggests hypnosis can retrieve hidden memories. The American Medical Association’s Council on Scientific Affairs found that recall during hypnosis can include confabulations and pseudomemories and appears less reliable than recall without hypnosis.⁸ Don’t invite that expectation on your form.
• A full trauma history. Ask whether there has been a recent traumatic event, not what happened. The details belong in a conversation, if at all.
• Sexual history, unless it is the issue the client is bringing, and then in conversation.
• Social Security number, insurance or employer details you won’t use.
• Questions that ask the client to diagnose themselves, such as “Do you have an anxiety disorder?” Ask what they’ve been diagnosed with and by whom.
• Anything you never read. If you’ve never used an answer, cut the question.

How you store the form matters as much as what’s on it. See HIPAA for hypnotherapists for when HIPAA applies and what to do either way.

When should you send the intake form?

Send it as soon as the first session is booked, and ask for it back at least 48 hours before. That leaves time to call about any yes answers and refer if needed, without cancelling on the day.

For returning clients, just ask what has changed: conditions, medication, goal.

In Hypnocube, a new client who books through your booking page gets the intake link in their confirmation email, and you can send it from the client file for sessions you book yourself. The link stays open for 30 days, answers save as the client types, and Today flags any client with a session in the next 48 hours who hasn’t sent it back. The epilepsy, psychosis and heart condition questions can’t be switched off, though you can add your own, including the others above.

How long should the form be?

Aim for 10 to 15 minutes, which is about 20 questions. Practical ways to keep it there:

• Make contact and screening questions short or yes/no.
• Mark only what you truly need as required: name, date of birth, the goal, the screening questions and the signature.
• Put the open goal questions near the start, while the client still has energy.
• Make it work on a phone.

For the rest of the pre-session routine, see reducing no-shows.

Intake form template

Copy this, change the practice name, and remove what you won’t use. Pair it with a separate consent form; see what to include in a hypnotherapy consent form.

CLIENT INTAKE FORM: [Practice name]

Thank you for booking. This form takes about 10 minutes. Your answers are
confidential and help me prepare for your first session.

1. ABOUT YOU
- Full name: ______
- Email: ______
- Mobile number: ______
- Pronouns (optional): she / he / they / prefer not to say
- Date of birth: ______
- Emergency contact (name and phone): ______
- Primary care doctor (name and practice): ______

2. WHAT YOU'D LIKE HELP WITH
- What would you like help with? ______
- When does it show up? Describe the last time it happened. ______
- What would a good outcome look like for you? ______
- Which of these is it about? (tick any)
  Sleep / Stress or anxiety / Confidence / A habit / Pain / A fear or
  phobia / Exams or performance / Weight / Other: ______

3. YOUR HEALTH
- Any physical or mental health conditions, past or current? ______
- Medication you take regularly, and any started or stopped recently: ______
- Have you had hypnotherapy or other therapy before? How did it go? ______
- Are you seeing a doctor, psychiatrist, psychologist or counselor about
  the issue you're bringing to me? If yes, who? ______
- If you're coming for pain: has a doctor assessed it? Yes / No

4. A FEW SAFETY QUESTIONS
These help me make sure hypnotherapy is a good fit for you right now. A yes
doesn't rule you out. It means we'll talk before your first session.
- Have you ever been diagnosed with psychosis, schizophrenia or bipolar
  disorder? Yes / No
- Have you ever had epilepsy or seizures? Yes / No
- Do you have a heart condition? Yes / No
- Are you currently being treated for a mental health condition? Yes / No
- Have you been through a traumatic or very distressing event in the last
  few months? Yes / No
- Have you had thoughts of harming yourself or ending your life in the
  last month? Yes / No
- Do you use alcohol or drugs in a way that you or others are worried
  about? Yes / No
- Anything else you'd like me to know? ______

If you are in crisis or thinking about suicide, call or text 988 (Suicide &
Crisis Lifeline) or call 911. Please don't wait for your session.

5. YOUR PREFERENCES
- Which of these do you find relaxing? (tick any)
  Ocean or water / Warmth or light / Forest / Counting down / A staircase
- Anything you find unpleasant or would like me to avoid (for example
  water, heights, enclosed spaces)? ______

6. CONSENT
[Your treatment consent wording, or a link to your consent form]
Type your full name to sign: ______   Date: ______

Footnotes

1. Bollinger JW — The rate of adverse events related to hypnosis during clinical trials. American Journal of Clinical Hypnosis, 2018;60(4):357-366. PubMed ↩

2. Rosendahl J, Alldredge CT, Haddenhorst A — Meta-analytic evidence on the efficacy of hypnosis for mental and somatic health issues: a 20-year perspective. Frontiers in Psychology, 2024;14:1330238. PubMed ↩

3. Häuser W, Hagl M, Schmierer A, Hansen E — The efficacy, safety and applications of medical hypnosis: a systematic review of meta-analyses. Deutsches Ärzteblatt International, 2016;113(17):289-296. PubMed ↩

4. Gruzelier J — Unwanted effects of hypnosis: a review of the evidence and its implications. Contemporary Hypnosis, 2000;17(4):163-193. DOI ↩

5. Wagstaff GF — Can hypnosis cause madness? Contemporary Hypnosis, 2000;17(3):97-111. DOI ↩

6. Sakellion D, Sultanov S, Irgashev D, Alimov U, Tsoutsi V, Dikeos D — Hypnosis: an ancient therapeutic practice revived in modern science (article in Greek). Psychiatriki, 2025;36(2):149-158. PubMed ↩

7. 988 Suicide & Crisis Lifeline. 988lifeline.org ↩

8. Council on Scientific Affairs, American Medical Association — Scientific status of refreshing recollection by the use of hypnosis. JAMA, 1985;253(13):1918-1923. PubMed ↩