Contact information
New Heart Centered Hypnotherapy Client Information Sheet
Email address *
Full Name *
Email *
Phone number *
Were you referred by anyone?
What condition, situation or experience would you like treatment for?
Please list the symptoms you would like to reduce or eliminate?
A favorite, relaxing place (such as the ocean, lake, trees, beach...)
Indicate if you are afraid of any of the following:
If you have a spiritual connection, please provide name or belief system (optional)
Your education level
Indicate any allergies
Name any medications you are currently taking
Do you have migraine headaches?
Are you currently receiving medical treatment or therapy?
Does this condition produce chronic pain or discomfort? Please explain.
Have you ever been in therapy?
If so, how long was the therapy?
Describe what symptoms you had and if or how the therapy helped
What brought you to Heart-Centered Hypnotherapy?
Anything else you want to tell me:
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