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Welcome to Balance Lab Certified Hypnotherapy, NLP, Neuromodulation services by Agnieszka Furtak.
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Email *
First Name *
Last Name *
Age *
E-mail Address *
Phone Number *
What city are you located in? (Therapy is available world wide) *
What days are you available for therapy sessions? - select all that apply *
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What times are you available for therapy sessions? - select all that apply *
Tell me about yourself. What is your current life situation? What are some of your current life stressors and challenges? *
What drew you to trying a holistic therapy? Why do you want to work with Aga? *
What goals do you want to achieve for yourself in the next 6 months? *
On a Scale of 1-5, how important is it to you to achieve your goals and overcome your current road blocks? *
What do you do for work and how long have you been doing that for? Do you feel burnt out or energized by your career? *
Have you been in therapy before? What was your experience like? *
How did you find Aga? *
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Crisis Resources If you are experiencing a psychiatric emergency please call 911 or go to your nearest emergency room. National Suicide Prevention Life Line1-800-273-8255Crisis Text LineText "HOME" to 741-741 National Domestic Violence Hotline1-800-799-7233The Trevor Project for LGBT youth, friends, and family members1-866-488-7386NAMI Crisis Text LineText "NAMI" to 741741 for 24/7, confidential, free crisis counselingTrans Lifeline877-565-8860
I have filled out this form to the best of my knowledge. I have reviewed the crisis resources. *
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