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    CLIENT INFORMATION INTAKE FORM

    The Client Information Intake Form consists of five Step. The first step is instructions and the second step concern your personal information. Step three contains the Challenges Checklist, please read each item on that page and put a Y (for yes) behind every item that applies to you (in any way), then go back and number each Y in order of priority. “1" is your highest priority, 10 is your lowest priority. It is okay to use more than one 1, more than one 2, but don’t make them all 1’s and 2’s. Do spread out your numbers. If an item doesn’t apply to you, leave it blank…. Don’t mark it a “10”.

    Step fourth briefly describes the Seven Keys. (There are only 7) On this page, number 1 has been entered for you on the Bronze Key blank, as it always has to be first. The rest of the blanks are to be numbered 2 through 7, using each number only once. Again, if they don’t apply to you, leave them blank.

    The last step is for office use only, please leave it blank.

    If you have any questions feel free to call us at Success Center, Inc. (818) 882-8512.

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    Client Information Intake Form

    PERSONAL INFORMATION

    NAME

    SEX

    AGE

    BIRTH DATE

    ADDRESS

    CITY

    STATE

    ZIP CODE

    HOME PHONE

    HOURS

    WORK PHONE

    HOURS

    CELL PHONE

    E-MAIL

    EMPLOYED BY

    EMPLOYER PHONE

    EMPLOYER ADDRESS

    CITY

    STATE

    ZIP CODE

    OCCUPATION

    AMOUNT OF YOUR EDUCATION & DEGREES HELD

    FAMILY MEMBER INFORMATION

    MARITAL STATUS

    SPOUSES NAME

    ANNIVERSARY DATE

    SPOUSE EMPLOYED BY

    CHILDREN (AGE/SEX)

    DOCTOR'S NAME

    DOCTOR'S PHONE

    IN EMERGENCY PLEASE NOTIFY

    RELATIONSHIP

    EMERGENCY ADDRESS

    EMERGENCY PHONE

    LIST A FEW SHORT-TERM GOALS

    LIST A FEW LONG-TERM GOALS

    PLEASE DESCRIBE ANY PRIOR HYPNOSIS EXPERIENCES

    RELIGION RAISED

    RELIGION NOW

    ATTEND SERVICESYesNo

    CURRENT HEALTH ISSUES

    CURRENT MEDICATIONS

    MY MOST IMPORTANT CHALLENGE IS?

    HOW WOULD YOU LIKE YOUR LIFE TO HAVE CHANGED IN ONE YEAR?

    IN FIVE YEARS?

    WHAT IS YOUR ULTIMATE GOAL IN LIFE?

    INTERESTS/HOBBIES

    HOW DID YOU HEAR ABOUT US?

    PUBLICATIONS (WHICH ONE?)

    RADIO/TV(STATIONS?)

    LECTURE (BUSINESS/ORGANIZATION NAME?)

    PERSONAL REFERRAL (WHO?)

    TRADE SHOW (WHICH ONE?)

    CONVENTION (WHICH ONE?)

    INTERNET

    OTHER

    ARE YOU ASSOCIATED WITH A BUSINESS/ORGANIZATION WHICH MAY NEED A SPEAKER OR SEMINAR LEADER? YesNo

    PLEASE SPECIFY

    I AM APPLYING FOR HYPNOSIS SESSION. I UNDERSTAND THAT MISSED APPOINTMENTS WILL BE FULLY CHARGEABLE TO ME AT REGULAR RATES. IF A 24-HOUR NOTICE IS GIVEN TO CHANGE APPOINTMENT, THERE WILL BE NO CHARGE

    DATE

    AGREEMENT

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    SUCCESS CENTER CHALLENGES CHECKLIST

    INSTRUCTIONS

    1. Please read each item BELOW and check off every item that applies to you in any way in the box to the RIGHT of the item.

    Example: Need more fun

    2. After you have finished checking each applicable item, go back and rate each checked item by the SCALE OF 1=HIGHEST TO 10=LOWEST in the blank to the left of the item.

    Example: Need more fun

    CHECKLIST

    This page contains the Challenges Checklist, please read each item on that page and put a X (for yes) behind every item that applies to you (in any way), then go back and number each X in order of priority. "1" is your highest priority, 10 is your lowest priority. It is okay to use more than one 1, more than one 2, but don't make them all 1's and 2's. Do spread out your numbers. If an item doesn't apply to you. leave it blank....Don't mark it a "10".

    Need a job/New job✓

    Personal✓

    Public speaking✓

    Worn out by job✓

    Blame others✓

    Fear✓

    Cannot save money✓

    Want to know my life mission✓

    Lack of skill✓

    Long Term✓

    Need more goals✓

    Poor vision✓

    Short Term✓

    Lack of skills✓

    - Wear glasses?YesNo

    Cannot get ahead✓

    Lack of motivation/ambition✓

    Desire to see well w/o glasses✓

    Problems w/ Co-workers✓

    Trouble making decisions✓

    Hearing impairment✓

    Employees✓

    Lack of education✓

    Cannot get up in the morning✓

    Boss✓

    - Willing to take classes?✓

    Get sick a lot✓

    Dislike Job✓ School✓

    Lack imagination✓

    Fear of

    Too much spare time✓

    Trouble with children✓

    Health getting worse✓

    Bad habits✓

    Trouble w/loved ones✓

    Mental state getting worse✓

    Drug problems✓

    Quarreling at home✓

    Aging faster than I prefer✓

    -Which drug?

    No time to relax✓

    Desire Rejuvenation✓

    Drink too much✓

    Need more fun✓

    Desire Healthy Longevity✓

    How much of what?

    Unwanted emotions✓

    Lack of energy✓

    Weight problems:✓

    Wanted emotions that are

    I take food supplements✓

    - Weight:

    absent✓

    Blood pressure✓

    - Height:

    Depressed -✓

    High✓

    - Desired Weight:✓

    How often?

    Low✓

    Eat too much✓

    Fear/Phobia✓of

    Menopause difficulties✓

    Sweets✓

    Afraid of people✓

    Allergies✓

    Junk foods✓

    Low self esteem✓

    To:

    Other✓

    Thought about suicide✓

    - Symptoms:

    Not enough exercise✓

    Last time: (date)

    Physical pain✓

    - Get:Need:

    Fear of dying✓

    Spiritual problems✓

    per Day / Week/ Month

    Too emotional✓

    Hard to meet people✓

    Dissatisfied w/ Appearance✓

    Too nervous✓

    Business✓

    Why?

    Guilt feelings✓

    Personal✓

    Want to quit smoking✓

    Negative reaction to stress✓

    Still grieving✓

    - I smoke cigarettes per day

    Social Anxiety✓

    Over

    Difficulty getting to sleep✓

    Difficulty relaxing✓

    (Who died):

    Cannot stay asleep✓

    Easily influenced✓

    - Yr. Mo.

    Poor memory✓

    Bad dreams✓

    Feel lonely✓

    Use to be better for

    Feel awkward✓

    Too shy✓

    Studying is dull✓

    Cannot express emotions✓

    Want a love relationship✓

    Read too slow✓

    - Specify:

    Sexual difficulties✓

    Poor concentration✓

    Dislike people✓

    Desire more sex✓

    Procrastinate a lot✓

    Frequent crying✓

    Unhappy marriage✓

    WorkPersonal

    Different from others✓

    Divorce✓

    Poor Organization✓

    How?

    Relationship breakup✓

    Time✓Space✓

    Fear responsibility✓

    Difficulty making friends✓

    Would like to raise income✓

    Too critical of others✓

    Am not assertive✓

    Present Income:

    Quick to anger✓

    Business✓

    Desired Income:

    Violent✓

    Personal✓

    What yr.

    Verbally abusive when angry✓

    Too pessimistic✓

    Desire a promotion✓

    Do not trust others✓

    Legal Problems✓

    Want to change:✓

    Too sensitive✓

    Have legal insurance?✓

    Business✓

    Afraid to take risks✓

    Do not communicate✓

    Job(s)✓

    In Business✓

    Work too dull✓

    Speech problems✓

    Feel sad frequently✓

    Other Concerns

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    THE SEVEN KEYS TO SELF-ACTUALIZATION USING SELF-HYPNOSIS

    This page briefly describes the Seven Keys. (There are only 7) On this page,number I has been entered for you on the Bronze Key Blank, as it always has to be first. The rest of the blanks are to be numbered 2 through 7, using earch number only once if they don't apply to you, leave blank.

    1

    AUTO-SUGGESTION AND SELF-HYPNOSIS………………………THE BRONZE KEY

    Develop heightened sensory awareness and the ability to better control your environment. Enhance emotional awareness, control and expression. Decision making skills and the Will to Learn are introduced. You will also begin increasing your ability to understand and remember the essence of what you read, see and hear.

    MEMORY ENHANCEMENT…………………………………………. THE COPPER KEY

    Develop a photo/phonographic memory, mental data correlation, speed-reading, effective test taking techniques and instant math intuition. Improve memory for names and faces. Anything required for better learning ability is unlocked with this Key.

    CREATIVITY…………………………………………………………… THE SILVER KEY

    Learn to be inspired at will! Remove all mental/emotional blocks to effective public speaking, writing and problem-solving. Enhance special talents such as art, acting, musical performance and composition. Apply your newly awakened creative skills to all areas of your life!

    SUCCESS……………………………………………………………. THE DIAMOND KEY

    Remove any mental or emotional blocks to your personal and business success through hypnotic age regression. Develop the skills and motivation necessary to create the career you’ve always wanted! With the Diamond Key you can easily apply the powerfully persuasive communication tools of “Neuro Linguistic Programming” for maximum success in business and career-related areas.

    BODY AWARENESS AND HEALTH TRANSFORMATION…………. THE GOLD KEY

    Develop abilities to manage stress, lower blood pressure, release excess weight. Your body cooperates with you to attain and keep your ideal shape and top health. Learn to release unnecessary discomfort, improve athletic abilities, enhance vision/hearing, and much more. Rejuvenation. The Hypnotic Fountain of Youth is available as a Gold Key Option.

    ESTABLISHING AND ENHANCING RELATIONSHIPS……………... THE RUBY KEY

    Singles learn to choose, attract and stay in a quality relationship with YOUR Right one (Matchmaking also available.)
    Already in a relationship? Make it even better! Parents, learn to be in a warm, positive relationship with your children--whether they be 5 or 45.

    SPIRITUAL GROWTH…………………………………………… THE PLATINUM KEY

    Meet your Spirit Guides and Higher Self. Explore your past lives. Develop your psychic abilities. Select from among telepathy, astral projection, precognition and other special talents. Advance option: Psychic diagnosis and the Healing Touch. HELPER/HEALERS enhance communication, interpersonal and helping skills of all kinds.

    The Bronze Key must be taken before any other Key. The rest may be taken in any order desired. Problem-resolution and achievement of individual goals will continue in all Keys.

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    Client Priorities

    (office use only)

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