VRishi Immersive Hypnotherapy

Life History Questionnaire

Jithendran Sellamuthu, C.MH. | AHA Cert 013165 | VRishi Hypno LLC

The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and accurately as you can, you will provide important information without using your actual session time. If you do not wish to answer a question, simply write “Do not care to answer.” All information is strictly confidential.

Your Information

Name

Age

Occupation

Marital Status

Who presently lives with you?

Referred by

Personal History

Describe your childhood in a few sentences

Describe your relationship with your mother

Describe your relationship with your father

Number of siblings and your position (oldest, youngest, etc.)

Were you raised by both parents? If not, please explain.

Education & Occupation

Highest level of education completed

What sort of work are you doing now?

Does your present work satisfy you? If not, in what ways?

Ambitions — past and present

Health

Describe your general health (good, fair, poor)

List any current medical conditions or ongoing health concerns

List any medications you are currently taking

Have you ever had any significant illnesses, surgeries, or hospitalizations?

Do you sleep well? Any issues with sleep?

Emotional & Psychological

Have you ever received counseling or psychotherapy? If yes, describe briefly.

What are your main fears or anxieties?

Underline any words that apply to you (or type them)

worthless, inadequate, stupid, guilty, anxious, agitated, cowardly, panicky, aggressive, ugly, depressed, unloved, misunderstood, bored, restless, confused, unconfident, full of regrets, worthwhile, sympathetic, intelligent, attractive, confident, considerate, assertive

Relationships

Describe your current relationship situation

What do you value most in a relationship?

Other Areas

Present interests, hobbies, and activities

How is most of your free time spent?

What do you regard as your main strengths?

What do you regard as your main weaknesses?

What would you most like to change about yourself?

Is there anything else you would like your practitioner to know?

All information is strictly confidential and will be used only for the purpose of preparing for your hypnotherapy sessions.

Client Signature (draw below)

Date

October 1, 2026