Your Horse is Your Mirror - Hypnotherapy Questionnaire
* Mandatory field

Your answers will be kept strictly confidential and deleted once your recording is finalised
Please fill out the following form, giving the first thought that comes to mind for each question that applies to you. The more information you supply, the better I can tailor your hypnotherapy to meet your needs.
Email *
Your Name *
Horse's Name *
Phone Number *
Today's Date *
MM
/
DD
/
YYYY
Male/Female
Clear selection
Occupation
Names of anyone else involved with your issues / your horse
1What are your 3 favourite colours? *
What are your 3 favourite places? *
3 Have you ever had hypnotherapy before *
. Would you prefer me to use words like relaxation and sleep, rather than ‘trance’ or do you have no preference? * *
How do you know your issue is a problem? *
What obstacles do you face because of this problem? *
List up to 3 of your hobbies or pastimes *
If you could wish to be, do or have something, what would it be? *
All of my life, I ………….
I am a person who………………….
What behaviours get in the way of your happiness on your horse? *
What would you like to start doing? *
What would you like to stop doing? *
What would you like to do more of? *
hat would you like to do less of? *
What are the things you feel you should, can, and must do?
What motivates you? *
What motivates you? *
Please list any specific needs or concerns or anything else that you would like included in your hypnotherapy.
Is there anything you would rather not have included in the hypnotherapy recording, please click on those things you would NOT want included *
Required
How would you like to end the hypnotherapy? – E.g. will you be listening in the daytime and want to be wide awake, or listening just before you go to bed, in which case, you’ll want to drift off to sleep. *
Please pay in advance of me creating your hypnosis. Select one of the options below *
RELEASE STATEMENT I hereby authorise Julia McHugh to produce for me a hypnotherapy recording for the purposes outlined in this intake form and for the future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability and desire to effect change in myself. I understand that the results of my sessions depend greatly on my own serious participation, and that Julia McHugh cannot offer any guarantee of the success Please print your name below. * *
A copy of your responses will be emailed to the address you provided.
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