Confidential Hypnotherapy Client Questionnaire

Your privacy is of utmost importance. All information provided will remain strictly confidential unless disclosure is legally required (e.g., risk of harm to yourself or others). You may omit any questions that cause discomfort. The more details you share, the better I can assist you. Please feel free to elaborate on any concerns or goals you’d like to address

Name

Age

Country

Phone number

Marital Status

Single

Partnered

Married

Separated

Divorced

Widowed

Name of Spouse/Partner if applicable

Names and ages of any children

Current Occupation

Do you like your work please explain why?

Have you experienced Hypnosis before?

Have you ever seen a therapist or mental health specialist? If yes, could you share a bit about your experience?

Are you dealing with any ongoing health issues? If so, we’d appreciate details about your condition and treatment.

Could you list any medications you’re currently taking, including dosage and any side effects you’ve noticed?

Do you have any fears, phobias, or habits you feel are hard to control?

Are there any life circumstances causing you stress or difficulty? Feel free to share anything that’s weighing on you.

What’s the main challenge you’d like help with?

Picture yourself free from this issue—how would your life change?

Do you tend to overthink things? (Yes/No)

Yes

If this pain were gone, what would you love to improve in your life?

Any current symptoms from the list provided?

Anxiety or nervousness

Difficulty relaxing or sleeping

Low mood or depression

Stress-related habits (nail-biting, teeth grinding)

Sleep disturbances or nightmares

Intimacy or sexual concerns

Compulsive behaviors

Substance use (alcohol, drugs, smoking)

Eating-related challenges

Self-harm tendencies

Focus or attention difficulties

Relationship struggles (marital, co-dependency)

Life transitions (divorce, grief)

Trauma (childhood, war, workplace)

Self-esteem or motivation issues

Neurodivergence (ADD/ADHD)

PTSD or abusive environments

Other (please specify)

Personal Preferences

1. Your two favorite places (ranked)

2. Your preferred relaxation methods

3. Your top two life goals

4. Hobbies you enjoy

5. Your biggest personal dream

Consent

Consent(Required)

hereby consent to hypnotherapy under the care of Dr. Azita Tavallaei, acknowledging

- Hypnosis is a non-medical modality.
- Results are contingent upon my engagement.
- No guarantees of outcomes are provided.
As a board-certified anesthesiologist and ASHH-certified hypnotherapist, Dr. Tavallaei will employ evidence-based techniques to facilitate my therapeutic goals.

بیمارستان تخصصی و فوق تخصصی اردیبهشت|1404

Ordibehsht Hospital

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