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Mind Talk Hypnosis Intake Form
Please fill out this form to the best of your abilities prior to our first session. This gives me the information I need to be as fully prepared as possible for our meeting and launching in to any assistance I can provide you.
Prefer not to say
When are the best times to reach you?
May we text you?
How did you find Mind Talk Hypnosis?
What would you like to accomplish within this session or a program of sessions?
What are other situations in your life that you'd like to resolve/improve? Choose all that apply.
Motivation / Procrastination
Self-Confidence / Self Esteem
Fears / Panic Attacks
Chronic or Acute Pain
Fears of Doctors/Dentists
Fear of Public Speaking
Have you been hypnotized, or has anyone attempted to hypnotize you, before? If yes, please give details.
Are you currently seeing a physician or counselor for a related issue?
Would you like to provide the name and any contact information of your physician /counselor?
Are you taking any medications or drugs? Please list.
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