Hypnosis Intake Form For Minors

Hypnosis Intake Form - Minor

This form is to be completed by the parent or legal guardian of the minor, except where noted.

At the end of this form, age-appropriate input from the minor is requested.

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 the child—not just the surface, but the deeper patterns that shape their experience.

The completed form is required no later than 24 hours prior to the appointment so that I can prepare.

Be advised completion may take up to 45 minutes.

Thank you for trusting me to support your child. I look forward to working with them!

Name of Child

First

Last

Preferred Name / Nickname

Child's Date of Birth

MM/DD/YYY

Gender

Pronouns

Emergency Contact

Name and phone

Address where client will take the session

(Used for emergency purposes only)

School / Grade Level

School Experience

Selected Value: 1

On a scale of 1-10, how would you rate the child's overall school outlook and experience? 1 does not enjoy it, 10 loves school.

Primary reason for seeking support:

Please use as much detail as possible.

What would success look like for your child?

Describe your "magic wand" for change. How will you know this work has been helpful?

How long has this been a concern?

In addition, if there was an initial event that led to the development of a pattern of behavior or phobia, please describe that here.

What makes managing this issue better?

Any coping skills, strategies, or circumstances that provide relief?

If your child has an addiction or compulsive behavior, please describe:

Be as detailed as possible naming triggers, the ritual/action, and describing the cycle from start to finish.

Has your child ever received counseling, therapy, coaching, or hypnosis before?

If yes, please describe when, what kind, and your satisfaction with the support received.

Current health conditions, medications, or allergies:

Previous Health Events

Please describe any procedures, surgeries, significant illnesses or hospitalizations.

Developmental History

Any significant delay in developmental milestones or learning challenges? Was the child carried to full-term?

Sleep Quality

Selected Value: 1

1 poor, 10 very good

Energy Levels

Selected Value: 1

1 low energy, 10 high energy

Nutrition Quality

Selected Value: 1

1 poor, 10 very good

Behaviorial or Emotional Patterns at Home or School

Please share how your child usually handles routines, rules, and changes at home and at school. Think about patterns over time, not single incidents.

Academic Strengths and Challenges

Where do they excel academically? What is academically challenging?

How does your child get along with peers and friends?

Are there any challenges or strengths you’ve noticed in their social interactions?

Extracurricular Activities / Hobbies

What do they do for fun?

Please describe how you guide or correct your child when rules are broken or challenges come up.

Examples of discipline might include time-outs, taking away privileges, talking about behavior, or other methods. Please share what works for your child.

What currently causes stress, worry, or big emotions for your child?

How does your child typically respond to, and cope with, stress or frustration?

For example: crying, screaming, withdrawing, isolating, becoming angry, or other reactions. What ways do they use to calm down?

Has your child ever expressed thoughts of self-harm, suicide, or harming others?

If yes, please explain briefly.

Any known history of trauma, abuse, or bullying?

If yes, please describe.

Loss history: identify all significant deaths in the child's life

Deceased's name, relationship to child, cause of death, child's age at time of death, and the nature child's grief

Has anyone else in the family (immediate or extended) ever had similar worries, fears, or habits as your child?

If yes, please describe who and how it showed up.

Family of origin

Two parent household? Single parent household? Blended family? Adopted? Donor conceived?

Family Relationships

Please list all parents/step parents/guardians, grandparents and siblings. For each, list name, if living/deceased, age. Describe the nature of each of these relationships in detail.

Religion/faith/spirituality

Does your family practice a particular religion, faith, or spiritual tradition?

Please list anything else that might be helpful for Kat to know.

Child Input: What would you like help with?

Child Input: After you meet your goal, how do you think life will be different?

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?

Child Input: Desire to Change

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.

Child Input: What makes symptoms worse?

For example, what triggers you? What makes things harder? Please be as detailed as possible!

Child Input: What makes managing it better?

What strategies help you feel better?

Child Input: How do you like school?

Selected Value: 1

On a scale of 1-10, what do you think of school? 1- I don't like it at all, 10- I like it a lot

Child Input: Who lives with you at home? Do you get along?

Parents, siblings, even pets!

Child Input: To really make changes, you'll need to practice what you learn in sessions at home. The exercises and tools will help you most when you use them regularly. Will you commit to this?

I agree to do my best at completing the homework assigned to me.

Child Input: If you were to close your eyes and imagine a familiar person, place, or object (like your bedroom or a family member's face), how clearly can you see it in your mind?

I see it as clearly as a real picture.
I see a vague or blurry image.
I see only shapes, outlines, or flashes.
I know what it looks like, but I can’t actually see anything.
I can't imagine it at all — it’s just blank.

Child Input: Who are your friends, and what do you like to do with them?

Child Input: What else do you like to do for fun?

Child Input: What is something in the past (big or small) that you have set out to do and have been successful?

This can be ANYTHING. Really!

Child Input: Please list anything else that you want Kat to know.

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.