A Beautiful Mind Clinical Hypnotherapy

We reach out when we find our symptoms overwhelm our ability to cope.

Answer the questions below if you choose.

Your answers will help me to tailor our therapeutic sessions for your specific goals.

The Presenting Issue Assessment below is designed to assist you in clarifying and understanding your needs and goals.

Complete it and return to us before you come in to your first appointment.

Note! Your answers are confidential and remain the property of A Beautiful Mind Clinical Hypnotherapy. Thank you.

Please do the following:

  1. Simply complete the Assessment below. Each space appears small but allows unlimited length to write your story.
  2. Respond briefly to the questions (including each part), but use complete sentences as much as possible.
  3. Take your time and think through the answers.
  4. Then click on SEND.
  5. After reviewing your answers, A Beautiful Mind Clinical Hypnotherapist will email a reply. If your answers are as complete and detailed as asked for in the questionnaire, this will save hours of interview time and thus save you money.

Presenting Issues Assessment

Your Name (required)

Please give your email address for a reply (Required)

Date of Birth

City and Province

What is your age and gender?

What is your marital status?
Single, married, separated, or divorced?
How long? Explain the reasons for separation(s) or divorce(s). What happened?

What is your race, ethnic, or cultural background?
(Caucasian, Chinese, East Indian, Aboriginal, Metis, Other?)

When and under what circumstances did your issue begin?

What is the nature and extent of the issue in your life?
Has it ever been different?

Under what circumstances does the issue tend to be more intense?
(When? Where? With Whom? Why? How?)

Do people you know have similar issues?
(Friends? Co-workers? Significant Others? Parents? Children? Etc.)

Do you know anyone personally who had their life negatively effected by an issue like this?

Do you know anyone who has mastered an issue like this?

Who in your life supports you in mastering this issue?

Any health problems?
e.g. epilepsy, diabetes, etc.

What other kinds of therapies have you tried to deal with this issue?

What lifestyle or attitude changes have been partially successful in dealing with this issue?

How much exercise do you get each week?
How is you eating habits?
Your sleeping patterns?

When was your last physical examination?
Are you under the care of a physician?
Are you taking any medications?
Do you have a diagnosed mental disorder?
Do you have ant history of seizures?
Hallucinations?

Do you associate any of these emotions with your issue? (Please Check the ones you associate with)

AngerAnxietyShame

SatisfactionGuiltRejection

FearFrustrationDepression

RomanceRelaxationSadness

BoredomGlamourEmbarrassment

LonelinessHappinessLoss or Grief

FemininityMasculinityAbandonment

Are there any other emotions? Please List them

Is there anything else you would like to say about your issue?

If you were to continue on a path of change and growth what would you hope to achieve?
What would be your goals in therapy?

What are your greatest strengths?
And what skills or abilities do you currently have the most confidence in?

What has this been like writing and reflecting on your life and your situation?

When you arrive for your first appointment, what specifically would you like to work on?
What do you believe you must do?
What would you like the therapist to focus on?

What type of support are you looking for?
1. Complete Wholistic Approach (Mind/Body/Spirit Treatment Protocol),
2. Therapy (Talk Therapy Only),
3. Therapy-Hypnotherapy (Talk + Hypnosis Only)

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