Client Intake Form. Please submit this form to apply for a hypnotherapy appointment with Karen. As soon as this form is received it is printed out and safely stored in a professional manner. No digital record is retained. For all other enquiries please visit the main Contact page here. Your first name Your surname Your preferred name Your address Your date of birth and age Your relationship status (single/married divorced/separated - how long?) Do you have children Y/N? If so, how many and what are their ages? Your Email Telephone number Health Doctor's name Date of last checkup (date/month/year) Are you taking any meditations? If so, what are they? Health Problems (past and current) From the following list please mark with an X the areas that concern you and give details where required. Abuse - past or present? Achieving goals Addictions - What are they? Anorexia or Bulimia Anxiety Career issues Concentration Confidence Depression Drinking Drugs Eating problems Exams Exercise motivation Fear Fertility Food or Dieting Gambling Guilt Hearing HypnoGastric banding Interview skills Memory Motivation Nerves or Panic Attacks Pain Control Phobias - What are they? Procrastination Public Speaking Relationships Relaxation Self Esteem Sexual Problems Skin problems / Younger Skin Sleep problems or Insomnia Smoking Stress Weight problems - slimming or weight gain What outcome would you like to achieve as a result of having hypnotherapy with Karen?