Body Kneadz Therapeutic Massage & Wellness Center LLC
INTAKE QUESTIONNAIRE: ELIZABETH KENNEDY
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Note: All information will be kept confidential except what we are legally obliged to report such as: threat to self or others. If you are uncomfortable with any of these questions, feel free to skip them, but be aware that the more you tell me about yourself, the more I may be of assistance to you. Feel free to use the back of the questionnaire to go into detail about anything you wish for me to know about you, or to help you with. It is my honor to assist you.
1.List your three favorite colors in order of preference:
2.List your three favorite places in order of preference:
3.On a vacation do you prefer relaxation or excitement?
4.List any fears/phobias
5. Do you experience any compulsive tendencies?
6.List any current health problems:
6.A Are you being treated by a physician?
If yes, for what?
6.B Are you being treated by a psychologist/psychiatrist/social worker?
If yes, for what?
7. List any medications you are currently taking:
7.B Please list any herbs and vitamins you regularly ingest:
8. Please list your three most important life-time goals:
9. Please list your three favorite past-times/hobbies:
10. What is your current occupation?
11. Do you enjoy your work?
12. Please list things that you like to do but that you want to be better at:
13.If you could be, do, have, or become anything, what would you wish for?
14. Why are you seeking hypnotherapy?
15. How did you hear about this office?
16. Are you currently experiencing any of the following: ( Please check all that apply )
other:
17. Do you follow any religious or meditative practices? (If so, please describe)
18. Please list any other conditions occurring in your life that you believe are negatively effecting you in any way.
19. Please use additional paper to tell me specifics of your needs/concerns, if necessary. (Page 4 provided for additional information purposes )
Release Statement: I hereby authorize Elizabeth Kennedy to hypnotize me for the purposes outlined in this intake form, and for future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my ability to relax and desire to create change in myself. I understand that because the results of my sessions depend greatly upon my own serious participation that Elizabeth Kennedy cannot offer any guarantee of the success of my treatment. I am aware however, that Elizabeth Kennedy will do everything reasonably in her power to ensure my success. (Please initial if submitting via email)
CHECKLIST FOR DISCOVERING LEARNING CHANNELS (Please check the number of any item that seems like something that fits your nature)
AUDITORY LEARNING CHANNEL INDICATIONS
1. Prefers to have someone else read instructions when putting a model together.
2. Reviews for a test by reading notes aloud or by talking with others.
3. Talks aloud when working a math problem.
4. Prefers listening to a cassette over reading the same material.
5. Commits zip code to memory by saying it.
6. Uses rhyming words to remember names.
7. Plans the upcoming week by talking it through with someone.
8. Prefers oral instructions from an employer.
9. Likes to stop at a service station for directions in a strange city.
10. Prefers talking/listening games.
11. Keeps up on news by listening to the radio.
12. Able to concentrate deeply on what another person is saying.
13. Uses free time for talking with others.
14. Sings or plays a musical instrument well.
VISUAL LEARNING CHANNEL INDICATORS
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 recipes easily when cooking.
5. Reviews for a test by writing a summary.
6. Writes on napkins in a restaurant.
7. Can put a bicycle together from a mail-order house.
8. Commits a zip code to memory by writing it.
9. Uses visual images to remember names.
10. Loves to read books.
11. Plans the upcoming week by making a list.
12. Prefers written directions from an employer.
13. Prefers to get a map and find own way in a strange city.
14. Prefers reading/writing games like SCRABBLE.
STRONG IN TOUCH/MOVEMENT (KINESTHETIC) CHANNEL
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 in typing.
5. Moves with music.
6. Doodles and draws on any available paper.
7. An out-of doors person.
8. Moves easily; well coordinated.
9. Spends a large amount of time on crafts and handwork.
10. Likes to feel texture of drapes and furniture.
11. Prefers movement games to games where one just sits (if age appropriate)
12. Finds it fairly easy to keep physically fit.
13. One of the fastest in a group to learn a new physical skill.
14. Uses free time for physical activities.
Feel Free to include any additional Information
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