Intake Form

You’ve taken the first step to ignite change! So that I can better support you, complete this form no later than 24 hours prior to our first session.

Please complete with as much detail as possible! Although some of these questions may not feel relevant, each helps me understand how to best support you—not just the surface, but the deeper patterns that shape your experience.

Be advised completion may take up to 45 minutes. Thank you!

Name
I would like to receive emails about upcoming events.
MM/DD/YYY
Name and phone
Selected Value: 0
On a scale of 1-10, how would you rate your overall satisfaction with your job/career? 1 not satisfied, 10 very satisfied.
If you were to close your eyes and imagine a familiar person, place, or object (like your childhood bedroom or a loved one’s face), how clearly can you see it in your mind?
Be descriptive as possible as to what you hope to accomplish or what your "magic wand" life would be like. What do you wish to experience as an outcome of working with me?
I understand that if I want deep, root-level change, I must commit to the work outside of sessions. The tools provided are only effective when I use them consistently and intentionally.
Selected Value: 0
On a scale of 1-10, how would you rate your motivation to make steps towards achieving this goal? 1 not very motivated, 10 very motivated.
In addition, if there was an initial event that led to the development of a pattern of behavior or phobia, please describe that here.
For example, what triggers you?
For example, what helps you gain clarity or momentarily feel free from the issue?
Describe how successful these strategies have been.
List as many benefits as possible. What will be different about your behavior? What will be different about your thinking? How will it feel? Who else might be impacted by your success?
List any current health conditions, medications you take regularly, and if you are currently working with a therapist, psychiatrist, or any other practitioner.
Amount/frequency of use and age when you started using
Two parent household? Single parent household? Blended family? Child of divorce? Adopted? Donor conceived?
Please list parents/step parents/guardians and siblings. For each, list name, if living/deceased, age. Describe the nature of each of these relationships in detail.
Please list partner/spouse and ALL other significant past relationships. For each, list name, if living/deceased, their age, the nature of the relationship, and the nature in which it ended (if applicable). If not currently in a relationship, describe a significant relationship you've had in the past and the nature in which it ended (divorce with custody battle, amicable break-up, etc).
Name, living/deceased, age, nature of relationships, and any co-parent(s) if applicable. If you do not have children, describe if parenthood or remaining childfree is part of your goals.
General Life Experiences (check all that apply)
If you marked any of the items above, please provide additional details and context.
Name, relationship to you, your age at time of death, cause of death, and the nature of grief
Describe the role religion, faith, or spirtuality has played in your life. Also mention if you believe in spirits/angels/higher power/past life/afterlife.
Hobbies, passions, activities, creative outlets, social outings...

Stay in Touch

Receive monthly inspiration and details on upcoming events!

Facebook Instagram Youtube
Copyright 2026 © All rights Reserved. Your Life Depot Hypnosis and Coaching, LLC.

Hypnotherapy and Health Coaching with Kat Shinoda
Board Certified Health Coach (NBC-HWC) and Board Certified Hypnotist offering effective methods for weight loss, smoking cessation, alcohol sobriety, and overcoming fears. Proudly serving Montgomery County and surrounding areas, including Collegeville, Skippack, Kimberton, Oaks, King of Prussia, Lansdale, Phoenixville, Pottstown, Reading, Royersford, Paoli, Coatesville, Trappe, Downingtown, Malvern, West Chester, Media, Ambler, Chalfont, Gilbertsville, and Philadelphia.