Dear Client,

The Intake Questionnaire below is the first step to the discovery, focus and self-healing of your challenge.

Enjoy and appreciate the journey.

After you have booked your appointment for a private hypnosis session with us, please return your completed form by email to

Manhattan Hypnosis
750 Third Avenue, 9th Floor
(between 46th & 47th Streets)
New York, NY 10017

Kindest Regards,

The Manhattan Hypnosis Staff


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Client Intake Questionnaire

CONFIDENTIALITY: All information received on this questionnaire will be kept strictly confidential.
INSTRUCTIONS : Please fill out the following form with your first thoughts only. Your first thought is the correct answer. Extensive descriptions will be discussed during the session.


Thank you.  The Manhattan Hypnosis Staff.

Today’s Date:________________________

Name:________________________________________ Date of Birth:________________________

Address:_______________________________________________________________   Sex: _____M _____F

City__________________________________________ State_______ ZIP ___________________


Daytime Phone: (______) ____________________

Evening Phone: (______) ____________________

Cell Phone: (_____)__________________________


Marital Status:____________________   Name of Spouse:_________________________________

Names & Ages of Children: ___________________________________________________________

List Three Favorite Colors:  ___________________________________________________________

1. List Three Favorite Places:  _________________________________________________________

2. List any fears: _______________________________________________________________________
3. Do you suffer any compulsive tendencies?
4. List any current health problems:
5. List any medications you are taking?
6. Please list your three most important lifetime goals:
7. Please list your three favorite hobbies:
8. What is your current occupation?
9. Do you enjoy your work?
10. Please list things that you like to do and want to do better?
11. If you could be, do, have anything, what would you wish for?
12. Why are you seeking hypnotherapy?
13. How did you hear about this office?
Magazine: Wisdom_______   NY Naturally_______   NY Spirit_______   Internet search engine_______   Google_______   Referral_______   Other_______
14. Are you currently suffering from any of the following? (Please Mark with X)
__ nervousness  __ poor health __ poor memory __ inability to relax __ cigarette smoking __ marital problems __ sleepless __ alcohol abuse __ recent divorce __ sadness __ compulsive overeating __ current illness __ nail biting __ compulsive tendencies __ teeth grinding __ lack of energy __ nightmares __ inability to focus attention __ death of a loved one __ abusive home situation __ lack of success __ fear of heights __ poor self-esteem __ other
15.One of the things I feel guilty of is:
16. I am happiest when:
17. If I were not afraid to be myself I would:
18. I get so angry when:
19. I am most saddened by:
20. All my life:
21. Ever since I was a child:
22. One of the ways I could help myself but don’t is
23. It is hard for me to admit:
24. I am a person who:
25. What behaviors get in the way of your happiness?
26. What would you like to start doing?
27. What would you like to stop doing?
28. What would you like to do more of?
29. What would you like to do less of?
30. What makes you laugh?
31. What makes you happy?
32. What makes you mad?
33. What makes you frightened?
34. What do you imagine yourself doing in the next 6 months?
35. What do you see or imagine yourself doing in 5 years?
36. What would have to change or be different for that to happen?
37. What are your main beliefs and values?
38. What are your main should, could, must, and ought to’s?
39. What motivates you?
40. In one word describe your life:
41. In one word describe your problems
42. One of the things I feel proud of is:
43. Do you observe any religious or meditative practices?
44. Do you believe in past lives?
45. Please explain any other negative conditions affecting you:
46. Please list any additional needs or concerns:

Neurolinguistic Learning Channel Profile

Instructions: Please X off characteristics that relate to your behavior.

1. Likes to keep written records [  ]
2.Typically reads billboards while driving or riding [  ]
3.Puts model together correctly using written directions [  ]
4. Follows written recipe easily when cooking [  ]
5. Writes on napkins in restaurants [  ]
6. Can put bicycle together using only written directions provided [  ]
7. Review for a test by writing a summary [  ]
8. Commits a zip code to memory by writing it [  ]
9. Uses visual images to remember names [  ]
10. A bookworm [  ]
11. Plans the upcoming week by making a list [  ]
12. Prefers written directions from employer [  ]
13. Prefers to get a map and find own way in a strange city [  ]
14. Prefers reading & writing games like scrabble [  ]
1.Prefers someone else to read instructions when putting model together [  ]
2.Reviews for a test by reading notes aloud or by talking to others [  ]
3.Talks aloud while working out a math problem [  ]
4. Prefers listening to a CD over reading a book [  ]
5.Commits zip code to memory by repeating it [  ]
6. Uses rhyming words to remember names [  ]
7. Review for a test by writing a summary [  ]
8.Talks to self [  ]
9. Prefers oral directions from employer [  ]
10. Stops at a service station for directions in a strange city [  ]
11. Prefers talking/listening games [  ]
12. Keeps up with the news by listening to the radio [  ]
13. Able to concentrate deeply on what another is saying [  ]
14. Uses free time while talking with others [  ]
1. Likes to build things [  ]
2.Uses sense of touch to put a model together [  ]
3. Can distinguish items by touch when blindfolded [  ]
4. Learns touch system rapidly when typing [  ]
5. Moves with the music [  ]
6. Doodles and draws on any available paper  [  ]
7. An out of doors person [  ]
8. Moves easily – coordinated [  ]
9. Spends large amount of time on crafts [  ]
10. Likes to feel texture of clothes and furniture [   ]
11. Prefers action activities [  ]
12. Finds it very easy to keep fit physically [  ]
13. Fastest in the group to learn a new physical skill [  ]
14. Uses free time for physical activities [  ]
Please Total each category above
Visual Number  [      ]       Auditory Number  [      ]       Kinesthetic Number  [     ]

Challenges Checklist
Place the appropriate number on the lines below on a scale of 1 to 5 (#1 is the most important while #5 is the least important). You may use number 1 (#1) more than once, for instance you may have three #1 challenges. Mark the issues that apply to you. You do not need to mark any challenge which does not apply to you.
___ Need a job
___ Worn out by job
___ Cannot save money  ___ long term  ___ short term
___ Cannot get ahead  ___ Problems with co-workers or boss
___ Dislike job ___school
___ Too much spare time
___ Bad habits (list) ____________________________________________________________________
___ Weight problems: Weight:___________ Height:___________ Desired Weight___________
___ Eat too much ___ sweets ___ junk foods Other (list) ________________________________
___ Not enough exercise  I get ____ minutes per day/week
___ Dissatisfied with appearance – Why?_______________________________________________
___ Want to quit smoking  I smoke ___ cigarettes per day
___ Difficulty getting to sleep  ____ Cannot stay asleep
___ Poor memory
___ Studying is dull
___ Read too slow
___ Poor concentration
___ Procrastinate a often  ___Work   ___Personal
___ Poor organization skills
___ Desire a promotion
___ Want to change  ___ business  ___ Jobs   ___ Work too dull
___ Afraid to take risks  ___ business  ___ personal
___ Blame others
___ Want to know my life mission
___ Need more goals
___ Lack of skills
___ Lack of motivation/ambition
___ Trouble making decisions
___ Lack of education classes
___ Lack imagination
___ Quarreling at home
___ No time to relax
___ Need more fun
___ Unwanted emotions (list) __________________________________________________________
___ Wanted emotions that are absent (list) ____________________________________________
___ Too pessimistic
___ Legal Problems
___ Fears of (list) _______________________________________________________________________
___ Afraid of people
___ Low self esteem
___ Fear of dying
___ Too emotional
___ Too nervous
___ Guilt feelings
___ Negative reaction to stress
___ Difficulty relaxing
___ Bad dreams
___ Feel awkward
___ Cannot express emotions (specify) ________________________________________________
___ Dislike people
___ Frequent crying
___ Fear responsibility
___ Quick to anger
___ Too critical of others
___ Verbally abusive when angry
___ Do not trust others
___ Too sensitive
___ Feel sad
___ Do not communicate
___ Speech problems (specify __________________________________________________________
___ Public speaking
___ Fears
___ Lack of skill
___ Hearing impairment
___ Cannot get up mornings
___ Get sick a lot
___ Fear of _health
___ Aging faster than I prefer
___ Desire Rejuvenation/Slow down aging
___ Lack of energy
___ Blood pressure  ___ High ___ Low
___ Physical pain (specify) ______________________________________________________________
___ Spiritual problems
___ Hard to meet people  ___ business  ___ personal
___ Feel lonely
___ Too shy
___ Want a love relationship
___ Desire more sex
___ Unhappy marriage
___ Divorce
___ Relationship breakup
___ Difficulty making friends
___ I am not assertive  ___ business  ___ personal
___ OTHER CHALLENGES (list) _________________________________________________________

Remember Hypnosis Changes Lives!


I hereby authorize a Manhattan Hypnosis hypnotist to hypnotize me for the purposes outlined in this intake form and for the future purposes that I may request. I understand that the success of my hypnosis depends greatly on my own ability and desire to affect change in myself. I understand that the results of my sessions depend greatly on my own serious participation and that Manhattan Hypnosis cannot offer any guarantee of the success of my session. I am aware, however, that Manhattan Hypnosis will do everything in their power to ensure my success. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen hypnosis at this time.

I understand that any electronic recordings that I have received from Manhattan Hypnosis (CD, MP3, other formats) for home use will only be used in environments where I am not driving; operating any heavy and/or sophisticated equipment or machinery or in any situations which require my complete and full attention.

Signature __________________________________________________   Date _____________________

I understand that during the hypnosis session, a hypnotist may touch me as an anchoring technique. I hereby give my permission for such touch to take place during my session.

Signature __________________________________________________   Date _____________________