Hypnotherapy Intake Form / HypnosisPS
Take your time to think about certain things and fill in this form as much information as possible. We will go over and discuss again at free consultation and 1st session. All information is private and confidential. HypnosisPS.com
Name *
Email *
Phone number - in case if email doesn't work
What is your situation of problem, issue or discomfort that you want to solve? *
When did your issue or discomfort start?
Do you have any major stresses in your life at present or earlier? If yes, briefly describe below:
What emotions do you associate with your issue? i.e. anger, guilt, discomfort, tension, fear, incoherent, etc.
Do you suffer any physical symptoms due to your issue? If yes, describe below:
What are you doing currently regarding the situation? i.e physical therapy, medical treatment, medications, meditation, yoga, other therapies, nothing
How will your life be like and how will you feel when you have changed and your issue is gone?
What activities and events do you want to do if you don't have the issue or discomfort?
Have you been hypnotized before? *
Thank you for your answers. Do you want to have free 30 min Zoom consultation? *
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