Sign up for a 15-minute free consultation for hypnotherapy/life coaching
MAGIS Therapies and Mindworks Neurofeedback Center is currently offering 15-minute free online consultations for those who need support and/or would like the opportunity to try hypnotherapy/life coaching. You can also answer this form if you wish to immediately start with hypnotherapy/life coaching session, you will just have to specify below your purpose of filling up the form.

For questions and/or clarifications, you may contact our team at:

To help us serve you in the best way possible, please provide the information below.

Please note that this is not a 24/7 hotline.
In case of emergency, or if you think your life or someone else's life is in danger, please call:
DOH-NCMH Hotline:
0917-899-USAP (8727)
0917-989-USAP (8727)
Or go to the nearest hospital within your vicinity.

All information provided is kept strictly confidential.

Sign in to Google to save your progress. Learn more
Email *
What service are you interested in? *
Please choose "15 minute free consultation" if you are answering this form to avail the free consultation, "Counseling Intake" if you are ready to start with the counseling sessions, "Group Therapy" if you wish to be enlisted for Support Group Therapy.
Where would you like your session to be held? *
If you're worried about being overheard at home by your family, or your internet connection is unstable, you can have your online session in our clinic without any additional charges. Staff will provide you with internet access and you will be provided with one of our soundproof rooms.  Kindly choose the option that suits you best
First Name *
Last Name *
Nickname *
Age *
Date of birth *
Gender identity *
Pronouns (How should we address you?) *
Civil status *
Complete address *
Email address *
Contact number *
Description of the problem or general concern *
You may be as detailed as you wish. Kindly note as well if you have been diagnosed by a psychiatrist.
Are you aware of what could be triggering your concern? *
Please write what triggers your concern and/or when it happens.
How long has this been a problem for you? *
How often does your concern take place? *
Have you sought therapy before? *
Please write the interventions you did in the past.
Are you taking any medications for your concern? *
Please enumerate the medications you are taking as of the moment, if any.
Is it your first time to seek hypnotherapy/life coaching? *
What is your preferred language for the consultation? *
Kindly indicate the days and times that work best for you to have a consult. *
To support you to the best of our capacity, please include an emergency contact.
Full name of emergency contact *
Emergency Contact's complete address *
Emergency Contact's contact number/s *
Emergency Contact's relationship to you *
I certify that the information provided in this form is true. *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy