Hypnotherapy Intake Form For Case Studies

HYPNOTHERAPY INTAKE FORM FOR CASE STUDIES

This case study explores the use of transpersonal hypnotherapy with individuals diagnosed with cancer at any stage. Participants will take part in six 1½-hour hypnotherapy sessions, with one session held each week for six weeks. Learn more about the case study here.

Application deadline: August 31, 2026

Date of Birth

Location of Birth

Time of Birth (If you don't know it, leave blank.)

Have you ever had hypnotherapy before?

Have you ever been diagnosed with mental health condition? If so, please list the diagnosis/diagnoses.

What type of cancer were you diagnosed with?

What stage of cancer is it?

Where are you currently in your cancer journey?

Recently diagnosed Currently undergoing treatment Completed treatment Living with ongoing cancer care

What treatments or medical care have you received or are currently receiving?

Surgery Chemotherapy Radiation Immunotherapy Hormone therapy Other

Are you currently working with a medical team for your cancer care?

What emotions have been most present for you during your cancer journey?

Fear Anger Sadness Grief Uncertainty Hope Gratitude Peace

For remote sessions, you must have a headset with an in-built microphone, a cam and wifi that's stable for 90+ minutes is required. Do you have these things?

List any additional comments you want to say below:

By submitting this application, I agree to this text:

The purpose of hypnotherapy is to support vocational and avocational self-improvement and to serve as an alternative or complementary approach alongside licensed healing arts services. A hypnotherapist is not a licensed physician or psychologist. Hypnotherapy itself is not a state-licensed practice. Hypnotherapy is non-diagnostic, and does not involve the practice of medicine. Hypnotherapists may assist clients with goals. This does not replace medical advice. Clients are encouraged to consult with their physician before making any medical, health or lifestyle changes. Hypnosis works with the subconscious mind which is believed to influence habits, emotions, motivations and attitudes. Through hypnosis many people experience positive changes in behavior and mindset. Sessions are structured around the client’s needs and may require an undetermined number of visits. The hypnotherapist will make every reasonable effort to support the client’s goals. However, the effectiveness of hypnosis varies from person to person and no specific results or progress can be promised or guaranteed. Experiences in hypnosis differ for each individual. Some remain fully aware while others notice heightened awareness, vivid sensations or an enhanced imagination. Many describe deep relaxation and relief from stress while still feeling alert and in control. Hypnosis may bring up memories or images of past events. Without supporting evidence, one may not be able to confirm the accuracy of such memories. While hypnotherapists generally maintain confidentiality, information shared during sessions is not protected by psychotherapist-patient privilege. In certain circumstances a court may order disclosure. I acknowledge that I have received and understand this disclosure. I have also reviewed the accompanying biography outlining the hypnotherapist’s education, training, experience and qualifications.