intake-form | Shoe Hypnosis

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Participant Information Questionnaire

Provided by Shoe Hypnosis LLC

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Client Address

Country/Region*

Address*

City*

Zip / Postal code*

Preferred Contact Method(s)*

Phone Call

Text

I understand that ordinary text messages and email may not be fully secure.*

I consent to appointment-related communications

Best Time to Contact You

Weekdays

Weeknights

Weekend Days

Weekend Nights

Emergency Contact Name*

Emergency Contact Phone #:*

Emergency Contact Relationship

In the case of emergency, 911 will be contacted. Emergency contact information will be used after emergency services have been called.

Reason for Seeking Hypnosis

Is your primary reason for seeking services related to a medical condition, mental-health condition, substance-use condition, eating disorder, sleep disorder, or symptoms of one of these conditions?*

Yes

Unsure

What would you like help learning or practicing? *

Self-hypnosis instructions

General relaxation

Stress-management education for everyday stress

Motivation, focus, or confidence related to a personal goal

Sports, performance, or public-speaking preparation

Procrastination or time-management habit support unrelated to a diagnosed condition

Other non-clinical self-improvement goal

If other, please briefly describe:

How long have you been working toward this goal or dealing with this concern?

What situations or patterns have you noticed?

What circumstances seem to make progress easier?

What circumstances seem to make progress more difficult?

Your Goals

Goal #1

Goal #2

Goal #3

What would you most like to accomplish through hypnosis?

If these sessions are helpful to you, what specific changes would you notice in daily life?

What observable changes would tell you that the sessions are useful?

The questions in the following sections help determine whether the requested non-clinical service appears to be within this practice’s scope and whether referral to, or written clearance from, a licensed healthcare or mental-health professional may be appropriate.

These questions are not a medical or psychological evaluation. The practitioner does not diagnose medical or mental-health conditions or determine medical or psychological fitness for hypnosis.

SERVICE SCOPE AND PRACTITIONER STATUS

Bryan Shoe provides non-clinical hypnosis education and coaching for self-improvement and performance goals.

Bryan Shoe is not licensed in Arkansas as a physician, psychologist, professional counselor, social worker, or other healthcare or mental-health professional.

Services do not include medical or psychological diagnosis, psychotherapy, professional counseling, medical treatment, crisis intervention, or advice to begin, stop, or change medication or other treatment. Services are not a substitute for care from a licensed healthcare or mental-health professional.

By checking this box, you acknowledge the above.

Health & Wellness Background

Primary Care Physician Name

PCP Phone #

Shoe Hypnosis understands that sharing your provider's information is not authorization to contact the provider.

Currently under the care of a physician or other healthcare professional? *

Yes

If yes, please explain:

Current significant medical condition(s)? *

Yes

If yes, please describe:

Are you currently taking any medication or using any substance that may affect alertness, breathing, memory, concentration, emotional stability, or your ability to give informed consent during a session?*

Yes

Unsure

If yes, please provide only the information you believe is relevant to safe participation.

Do you have any allergy or environmental sensitivity that could affect an in-person session, such as sensitivity to fragrance, latex, cleaning products, or animals?*

Yes. Please explain:

Scope and Participation Screening

IMPORTANT CRISIS INFORMATION

This practice does not provide emergency or crisis services, and this form is not monitored continuously.

If you are in immediate danger, are thinking about suicide or harming yourself or another person, or are unsure that you can remain safe, do not wait for a response from this practice. Call 911, call or text 988, or go to the nearest emergency department.

By checking this box, you acknowledge the above.

MEMORY AND FORENSIC LIMITATIONS

Information, images, impressions, or memories that arise during hypnosis may be incomplete, distorted, symbolic, or inaccurate.

Hypnosis will not be used to verify facts, recover supposedly accurate memories, determine whether an event occurred, investigate suspected abuse, prepare testimony, or support a legal claim.

Any imagery or recollection arising during a session should not be treated as proof that an event occurred.

By checking this box, you acknowledge the above.

Are you currently receiving care from a licensed mental-health professional? *

Yes

Has a licensed healthcare of mental-health professional advised you not to participate in hypnosis, focused-imagery, or relaxation exercises?*

Yes

Unsure

Are you seeking these services primarily to diagnose or treat a mental-health condition? *

Yes

Unsure

Are you currently experiencing symptoms that make it difficult to distinguish what is real, remain oriented to your surroundings, or provide informed consent?*

Yes

Unsure

Within the past 12 months, have you received emergency or inpatient care for a mental-health crisis?*

Yes

Do you need any communication, mobility, sensory, scheduling, or other reasonable accommodation to participate?*

Yes. Please describe:

Substance Use

Sessions cannot be conducted while a participant is intoxicated, impaired, or experiencing withdrawal.

Is there any current alcohol, cannabis, non-prescribed drug, or medication use that could affect your ability to participate safely and provide informed consent?*

Yes

Unsure

If yes, please explain:

Sleep

Is there anything about your current sleep, fatigue, or daytime alertness that could affect your ability to participate safely in a session?

Yes. Please explain:

Lifestyle

Stress Level

5. Very high

4. High

3. Moderate

2. Low

1. Very low

Primary source(s) of stress:

Do you exercise or perform regular physical activity?

Yes

If yes, please describe the experience:

Do you participate in any of the following?

Meditation / Mindfulness

Breathing exercises

Yoga

Prayer

Guided imagery

Self-hypnosis

None

Other

Previous Experience with Hypnosis

Do you have previous experience with hypnosis?

Yes

If yes, please describe the experience:

If applicable, you would describe your previous experience as:

4. Very helpful

3. Somewhat helpful

2. Neutral

1. Not helpful

Other

What are your expectations regarding hypnosis?

Do you have any concerns, fears, or questions about hypnosis? If so, please share.

When a scene or object is described to you, how well are you able to mentally visualize what is being described (on a scale from 4K definition to words/nothing)?

Personal History

Is there any information directly related to your stated non-clinical goal or your ability to participate safely that you would like the practitioner to know?

Please do not provide a detailed trauma history on this form. If trauma, abuse, or a diagnosed mental-health condition is central to your request, the practitioner may recommend that you work with an appropriately licensed professional.

Is there anything else about your physical/emotional wellness, history, lifestyle, or circumstances that you would like to share?

At the beginning of each remote session, you will be asked to confirm your current physical location and an emergency contact. Services may be discontinued if your location cannot be confirmed.

Please acknowledge that this review of your health background is not an evaluation, diagnosis, or clinical assessment. This background information is gathered solely to identify lifestyle factors and ensure there are no safety contraindications to deep relaxation techniques

CONFIDENTIALITY AND PRIVACY

The practice will use reasonable measures to protect the information you provide, subject to the Privacy Notice and applicable law.

Information may be disclosed with your authorization, when required or permitted by law, in response to valid legal process, or as described in the practice’s emergency and safety policies.

Because the practitioner is not a licensed psychotherapist, counselor, psychologist, or healthcare professional, you should not assume that communications are protected by psychotherapist-patient, counselor-client, or healthcare-provider privilege.

PARTICIPANT ACKNOWLEDGMENT

By signing below, I confirm that:

The information I provided is accurate to the best of my knowledge and that I will notify the practice of material changes relevant to my participation.
I understand that Bryan Shoe is not licensed in Arkansas as a physician, psychologist, professional counselor, social worker, or other healthcare or mental-health professional.
I understand that the services offered are limited to non-clinical hypnosis education and coaching for approved self-improvement or performance goals. They do not include medical or psychological diagnosis, psychotherapy, professional counseling, medical treatment, crisis intervention, or advice to begin, stop, or change medication or other treatment.
I understand that these services are not a substitute for care from a licensed healthcare or mental-health professional. I will continue appropriate licensed care and seek emergency care when necessary.
I understand that participation is voluntary, results vary, no particular outcome is promised, and I may decline any exercise or stop a session at any time.
I understand that completing this form does not guarantee that services will be accepted or provided. The practitioner may recommend referral to or written clearance from a licensed professional.
I understand that AI will be utilized to process the information provided in this form to optimize a hypnosis path that addresses my goals.

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