Intake form MMC kids (ENGLISH)
By: Floranita. CHt® of Mind Miracle Center
Date: *
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Name and Age: *
Gender: *
Address and City *
Mobile Phone number: *
Mother Language: *
Religion: *
Name of father: *
Name of mother: *
Occupation of Mom or Dad: *
Number of siblings:
Clear selection
How do you happen to know about us? *
If someone referenced you to us , please mention who did:
Child's Hobby : *
Natural scenery that the child loves: *
Child's favorite character: *
Other information about what the child likes: *
What does the child often imagine / play in the imagination? *
How is the child's relationship with her/his father? *
How is the child's relationship with her/his mother? *
Now, is the child currently in the care of a psychologist or doctor for this problem? *
If yes, where? , Name of Psychologist / Psychiatrist / Doctor
Has the child ever received treatment for problems related to emotions? *
If yes, are you currently undergoing counseling / therapy?
Clear selection
If yes, who is conducting counseling or therapy?
Have you (parents) ever undergone a hypnotherapy procedure before? *
If you answered "Yes," answer the following question: For what reasons?
If you answer "Yes" answer the following question: Do you believe that you were successfully hypnotized at that time?
If you answered "Yes" answer the following question: Why?
If you answered "Yes", answer the following questions: In general, how was your hypnosis session?
If you answered "Yes", answer the following question: Why did you come here?
Do you have any questions about hypnotherapy? If yes, write the question.
Tell us about the problem of the child that you want to solve/ problem that this child is facing. *
How long has this problem bothered you? Or since when you started to realize this problem *
Have you tried to solve this problem before? If yes, what are the results? *
Write down at least 7 benefits if this problem is solved. *
Write down what attitudes or thoughts you, as a parent, might have hindered/interrupted the change you dreamed of: *
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