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