Intake Form Hipnoterapi

Rahasia FORM DATA PRIBADI DI KLIEN DEWASA PUSAT LAYA LAYANAN HIPNOTERAPI HIPNOTER API

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Tangg Tanggal al terapi:… terapi:…………… …………Jam Jam terapi…… terapi…………… ………….(d ….(diisi iisi penerim penerima a telpon) telpon) Nama : ..................... .................................. ......................... ......................... ......................... ......................... .............(L/P) (L/P) Alamat: ....................... ................................... ......................... ......................... ......................... ......................... ........................ ........................ .............. ......................... ..................................... ........................ ........................ ........................ ........................ ........................ ........................ ......................... ............... !ota: ...................... .................................. ........................ ........................ ......................... ......................... ......................... ......................... .................. ...... No. Telp: Telp: ......................... ..................................... ........................ .............#P:....... .#P:................... ........................ ........................ .................... ........ %mail: ..................... .................................. ......................... ........................ ......................... ......................... ......................... ......................... ................ .... Tempat Tempat dan tgl lahir: ....................... .................................... ......................... .......................' ...........'sia:...... sia:................... ................. .... ahasa *+' saat 'sia & tah'n ,e +a-ah : ......................... ...................................... ......................... ................... ....... tat's perni,ahan: perni,ahan: ....................... .................................... ......................... ......................... ......................... ........................ ................... ....... Agama: ....................... ................................... ........................ ........................ ........................ ........................ ......................... ......................... .............. .. J'mlah ana,: ........................ .................................... ......................... ......................... ........................ ........................ ........................ ................ .... Pe,eraan: Pe,eraan: ...................... ................................... ......................... ......................... ......................... ........................ ........................ ..................... ......... #o+i: ..................... .................................. ......................... ........................ ......................... ......................... ......................... ......................... .................. ...... Pemandangan Pemandangan alam ang anda s',ai: ........................ ..................................... ......................... ........................ .............. Apa,ah Apa,ah ang ang sering sering anda anda ,haal,a ,haal,an/ma n/main,a in,an n se-a,t' se-a,t' masih masih ,eil4 ........................ ..................................... ......................... ........................ ........................ ........................ ........................ ........................ ................ .... .......... ......................... ..................................... ........................ ........................ ........................ ........................ ........................ ........................ ......................... ............... Anda adalah ana, ,e ..................dari ..................dari ...................... ..............................+ers ........+ersa'dara a'dara aat aat masih masih ana,5 ana,5an ana,/ a,/rem remaa aa:: a. agaimana agaimana relasi Anda Anda dengan aah4 ...................... .................................. ........................ ............... ... +. agaimana agaimana relasai Anda Anda dengan *+'4 ...................... ................................... ......................... ............... ... agaima agaimana na anda anda tah' mengena mengenaii ,ami4 ,ami4 a. 'rat ,a+ar  +. 6e+site . Re7erens Re7erensii i,a re7erens re7erensi8 i8 siapa siapa ang ang mere7ere mere7erensi4 nsi4 ........ ............ ........ ........ ........ ........ ....... ... ....................... ................................... ........................ ........................ ......................... ......................... ........................ ......................... ............... aat ini8 apa,ah anda sedang dalam penangangana penanganganan n psi,olog ata' do,ter 'nt', masalah anda ini4 .................................................................................. Ji,a 9a8 dimana4 ............................................................................................. Nama Psi,olog/Psi,iater/o,ter4 .................................................................... Apa,ah anda pernah dalam pera-atan pera-atan do,ter ,arena sa,it di tah'n5tah'n tah'n5tah'n se+el'mna4 a. 9a +. Tida, Ji,a 9a8 Anda sa,it apa dan siapa nama do,ter ang menangani anda4 ......................... ..................................... ........................ ........................ ........................ ........................ ........................ ........................ ......................... .............

21.

Apa,ah anda pernah mendapat mendapat penanganan penanganan 'nt', masalah ang +erh'+'ngan dengan emosi4 a. 9a

P'sat Laanan #ipnoterapi

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+. Tida, Apa,ah anda mengalami sa,it: a. Jant'ng +. ia+etes . %pilepsi d. ................. ...................................................  Apa,ah anda saat ini min'm o+at4 Ji,a 9a8 o+at apa4  Alasan min'm o+at4 Apa,ah p'na sa,it ang menah'n4 a. 9a +. Tida, Ji,a 9a8 sa,it apa4 ........................................................................................ eri tanda pada masalah5masalah 7isi, +eri,'t ini ang sering Anda alami: a. in's +. !a,i terlal' dingin . !ram saat menstr'asi ata' tida, lanar  d. !a,i ,a,' e. em+elit 7. aria-an/g'si l',a g. P'nda, ,a,' h. P'ngg'ng atas ,a,' i. Leher +ela,ang ,a,'  . !a,i +eng,a, ,. Asam lam+'ng +erle+ih l. Tangan terlal' dingin m. !ram/,a,' pada tangan dan persendian Apa,ah anda pernah dihipnosis se+el'mna4 a. Pernah +. Tida, pernah Ji,a Anda mena-a+ ;pernah; a-a+lah pertanaan +eri,'t ini:
P'sat Laanan #ipnoterapi

31.

T'lis,an si,ap ata' pemi,iran apa ang ,ira5,ira +isa mengahalangi per'+ahan ang Anda impi,an: .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... ..........................................................................................................................

32.

T'lis,an minimal & ,e'nt'ngan i,a Anda +e+as dari masalah ini: a. ............................................................................................................... +. ............................................................................................................... . ............................................................................................................... d. ............................................................................................................... e. ............................................................................................................... 7. ............................................................................................................... g. ............................................................................................................... h. ............................................................................................................... i. ...............................................................................................................  . ...............................................................................................................

P'sat Laanan #ipnoterapi