Somatic Hypnotherapy Intake Form

Section 01

About You

First Name *

Last Name *

Preferred Nickname

Date of Birth *

Preferred Pronouns *

She/her They/them He/him Other

Relationship Status

Select all that apply.

Email *

Phone *

Emergency Contact Name *

Emergency Contact Phone *

Section 02

Insurance Receipt

Would you like an insurance receipt? *

Verify with your provider that they cover Naturotherapists under the ACNN (Academy of Naturopaths and Naturotherapists of Canada).

Yes No

Street Address

Address Line 2

City

Postal Code

Section 03

Session History & Focus

Have you received hypnotherapy or somatic work before?

Yes No

If yes, briefly describe modalities and experience *

Which areas would you like to focus on?

Select all that apply.

Pain / Symptom Relief Somatic Healing & Emotional Processing & Regulation Anxiety & Stress Relief Confidence & Self-Esteem Sleep Improvement Creating Boundaries Highly Sensitive Person (HSP) Support Inner Child & Parts Work (IFS-Informed)

Section 04

How You're Doing

Sleep Patterns

Select all that apply.

Fall asleep easily Wake up feeling rested Difficulty falling asleep Trouble waking up / unrested Wake in the middle of night

Stress Levels *

Pace of Life *

Mental Health — How balanced do you feel? *

Section 05

Mental Health & Support

Are you currently working with a licensed mental health professional?

e.g. therapist, psychologist, psychiatrist

Yes No

If yes, please briefly describe the support you're receiving

Have you ever been diagnosed with a mental health condition?

If so, please share the diagnosis

Have you ever been psychiatrically hospitalized?

If so, roughly when, and anything you're comfortable sharing

Do you have epilepsy or a history of seizures? *

Yes No

Are you currently experiencing, or do you have a history of, depression, significant emotional distress, or thoughts of suicide or self-harm?

It helps me hold our work together with care — and if any of this feels present for you, connecting with a licensed mental health provider alongside our sessions can help too. If your safety ever feels at risk, please reach out to a crisis line or emergency services right away.

Yes No

Section 06

Goals & Boundaries

What specific goals, intentions, or areas of your life would you like to focus on in our sessions?

Have you experienced any physical or emotional trauma that may be relevant to our work?

Personal boundaries, comfort levels, or concerns — including any sensitivities, mental/emotional/physical *

Any medical conditions, physical limitations and injuries, or medications (including psychiatric) I should be aware of? *

Section 07

One Last Thing

How did you hear about Rio? *

Anything else you'd like to share?

Section 08

Consent & Signature

Date *

Signature *

Sign with your mouse or finger

Somatic HypnotherapyIntake

Intake received

About You

Insurance Receipt

Session History & Focus

How You're Doing

Mental Health & Support

Goals & Boundaries

One Last Thing

Consent & Signature

Somatic Hypnotherapy
Intake