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Client Intake Form

Client Information

Client Name
Client Name
First
Last
Gender
Marital Status

General and Mental Health Information

Permission to contact Doctor

Hypnotherapy

Therapy Outcomes

Basics Assessment

Behaviour

Affect

Sensations

Imagery

Ask the client to close their eyes and imagine they are doing the behaviour(s)).

Cognition

Self-Talk

In respect of the behaviour(s) you have described:

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