Equestrian Hypnotherapy Questionnaire
Email address *
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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.
Name *
Your answer
Horse's name *
Your answer
Today's date *
Your answer
Male/female
Occupation
Your answer
Email *
Your answer
Phone number
Your answer
Names of anyone else involved with your issues / your horse
Your answer
1. What are your 3 favourite colours?
Your answer
2. What are your 3 favourite places? *
Your answer
3. Have you ever had hypnotherapy before *
4. Would you prefer me to use words like relaxation and sleep, rather than ‘trance’ or do you have no preference? *
5. How do you know your issue is a problem? *
Your answer
6. What obstacles do you face because of this problem?
Your answer
7. List up to 3 of your hobbies or pastimes *
Your answer
8. If you could wish to be, do or have something, what would it be?
Your answer
9. All of my life, I ………….
Your answer
11. I am a person who………………….
Your answer
12. What behaviours get in the way of your happiness on your horse? *
Your answer
13. What would you like to start doing? *
Your answer
14. What would you like to stop doing? *
Your answer
15. What would you like to do more of? What would you like to do less of? *
Your answer
15. What are the things you feel you should, can, and must do?
Your answer
16. What motivates you? *
Your answer
17. Please list any specific needs or concerns or anything else that you would like included in your hypnotherapy.
Your answer
18. Is there anything you would rather not have included in the hypnotherapy recording, please click on those things you would NOT want included *
19. 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. *
20. Would you like an MP3 or CD+MP3 of your recording? *
21. If you would like a CD, please supply your postal address
Your answer
RELEASE STATEMENT I hereby authorise Tracey Cole 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 Tracey Cole cannot offer any guarantee of the success Please print your name below. *
Your answer
Contact details
info@traceycolenlp.com
From the UK 07815016169
Outside of the UK ++ 44- 7815016169
Skype traceycolenlp

www.traceycolenlp.com
For more information on hypnosis for equestrians see https://www.traceycolenlp.com/equestrian-hypnotherapy/

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A copy of your responses will be emailed to the address you provided.
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