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Introductory Questionnaire for Impactful Changes Hypnosis
Hello,

My purpose in this questionnaire is to get a more complete picture of you as a human being. To better assist you with my professional abilities, knowledge is essential, and every piece of information you feel comfortable sharing with me will enhance our sessions together and will greatly reduce the time needed to get your desired results.

Of course, if you feel uncomfortable with a question, do not answer it. There is no obligation or commitment in filling out this simple form. Answering any kind of question may give you some insights about your life and habits, the kind of knowledge that is always beneficial when you come to your session.

Now, before you start, I want you to understand clearly- I NEVER share your private information with ANYONE. Besides the fact that it's against the law, I respect your privacy and confidentiality is my first and most important priority. Only you can provide the permission to show this form or any other document in my office to someone besides you and I. Even my Staff Members don't have access to your private information.

Please take as much time as you need to fill out this form. I gave it to you to do it at home and/or in private so you won't have to spend our session time on standard forms. I will use this form to do my own homework before our next session, to make sure that you get the most out of our time together. My livelihood and income are dependent on my success with my clients, and that is how important your progress and improvement are to me.

If you feel the need of any kind to ask for assistance with a question, please do not hesitate to call me directly. I will appreciate your comments and suggestions as always.

With love and warm regards,

Adam Goodson
Impactful Changes Hypnosis
619.564.2322

What is your first name?
Your answer
What is your middle name?
Your answer
What is your last name?
Your answer
What is the best phone number to reach you at?
Your answer
What is the best email to contact you?
Your answer
What is your Relationship Status?
What is your Address?
Your answer
You were refereed by:
What is your Educational Level?
Describe the people that you live with and who the role models are in your life:
Your answer
Describe your work life:
Your answer
What types of jobs did you hold in the past?
Your answer
Does your present work satisfy you? And if not, in what ways are you dissatisfied?
Your answer
How much does daily life cost you(rent, food, travel, kids, etc) ?
Your answer
List your past ambitions in your life:
Your answer
List your present ambitions in your life:
Your answer
What are the challenges or problems you have that have allowed you to seek me in our sessions?
Your answer
How long does each problem exist in your life? When did it start and what happened during that time?
Your answer
How severe would you rate these problems?
Did you seek counseling with a professional in the past regarding these problems?
If you selected "yes" for the previous question, please describe what took place then.
Your answer
Mark any of the words which apply to you:
List and describe your present hobbies and interests:
Your answer
What do you normally do with your free time?
Your answer
In school or after school, were you ever teased or bullied?
Your answer
Do you make friends easily?
Prioritize your 5 major fears
List your biggest fear first, followed by the next 4 biggest fears from the greatest to least, only the top 5 though.
Your answer
Of the following condition, which ones happen once or more per week?
Complete the following sentence: "I am....."
Your answer
Complete the following sentence: "And I am also....."
Your answer
Complete the following sentence: "I wish I were....."
Your answer
Complete the following sentence: "I wish I were also....."
Your answer
Complete the following sentence: "I wish I had....."
Your answer
Complete the following sentence: ""I wish I had also....."
Your answer
Complete the following sentence: "I think I could....."
Your answer
Complete the following sentence: "There is no chance for....."
Your answer
Complete the following sentence: "I appreciate....."
Your answer
How do you define Being Successful for yourself?
Your answer
And lastly, what do you expect from me as your hypnotherapist, and from our sessions together? Is there anything you believe I should know about before we begin, to make our sessions more focused?
Your answer
Thank you for filling out this form and someone will be contacting you very soon.
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