Ascension Hypnosis

***PLEASE NOTE:

This form helps me, Andrea Young to have a baseline knowledge of why you have come to hypnosis and your personal history as YOU define it on your path to healing and wellness; if you prefer to skip a question or tell me something verbally instead of writing about it that is 100% perfect!

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~You *must* reach out to book with me via Instagram, email or text (No Facebook plz) -> When booking please tell me your name and social media @ and NEW BOOKING in your subject line, even if you are a returning client.

~Filling in this form is NOT a booking

~I make my schedule myself to accommodate my own boundaries, peace of mind and chronic illness/pain management :)

@youngascensionhypnosis

youngascensionhypnosis@gmail.com

1-438-882-4976



This form helps me, Andrea Young to have a baseline knowledge of why you have come to hypnosis and your personal history as YOU define it on your path to healing and wellness; if you prefer to skip a question or tell me something verbally instead of writing about it that is 100% perfect!
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Email *
All your names: please include legal name, chosen name, social media @, art name, as well as the email *from which you will be paying me or contacting me* *
Pronouns, Gender Identity & relevant details: *
Contact Info *
Email, skype or phone number (for the purpose of following up or connecting for online sessions)
Why have you come to Hypnosis? How would you prefer to feel? *
Are there any boundaries or topics you do NOT wish to touch upon? *
Tell me about your sleep hygiene and morning routine: *
What other Healing Modalities have you sought for these issues and in general? *
Have you ever experienced Hypnosis? Do you meditate, if so please describe your practices/personal history and frequency: *
(please detail)
What scents or flavours do u like and why? *
What is your morning beverage? What flavour of tooth paste do you use? *
Do you currently have an chosen rituals or commitments to pleasure or self-care related to the 5 senses that you are already working with (it is possible in hypnosis to "stack" these habits with new limbic system and subconscious associations) i.e.: I always drink green tea first thing in the morning, I have a diffuser by my bed with lavender essential oils, I try to keep fresh cut flowers in my house at all times, etc. *
Please Describe your Spiritual Beliefs: *
Relationship Status: current or previous significant/relevant dynamics or abuse (please include names if relevant): Do you have children? Please detail any pregnancies, abortions or miscarriages yours or your partner’s (reasons for terminations at the time): *
Have you any significant accidents/trauma/surgeries: *
Please describe your relationship to recreational drugs and alcohol: *
Please detail your history and your family history of mental health struggles depression/anxiety or addiction. Please detail your relationships with your family/ancestors and intergenerational trauma? *
Regarding Visualizations, what is appealing to you *
Required
Some place or thing that you find peaceful or reassuring *
Required
Do you have a specific place in nature (or otherwise) that feels like your own private paradise? Somewhere you can access IRL and regularly is preferred but not necessary *
Any place you feel uneasy or fearful? *
What kind of books, stories, films do you currently like AND which did you like as a child? *
ex: spies, fairy tales, historical fiction, fantasy, sci-fi
How do you spend your time? What are your day to day schedule and limitations. Where is your income coming from (this is important for sliding scale & scheduling but also to give me a sense of your life) Please Describe: *
Please indicate your pertinent health history & current medications: *
Add your Physician’s Name and Number in case of emergency
How did you find Ascension Hypnosis? Please be specific as possible if it is a post, article, pal etc: *
PLEASE READ:
I hereby authorize, Andrea Young, to hypnotize and or use guided imagery with me for the purposes outlined herein, and for any future purposes I request. I understand that my results depend on my ability to relax and my investment in the process. I understand that hypnosis/guided imagery is not a medical or psychiatric procedure. I am aware and trust that Andrea Young will do everything in her power to ensure my success. I understand that these sessions may be recorded and that all materials and information exchanged in these sessions will remain completely confidential. Andrea Young does not offer guarantees of success of her sessions. I understand that this process is participatory and that I am complicit. I feel comfortable asking questions. * any packages must be paid in full at time of purchase and are non-refundable* By signing (or typing your name) you agree that you have read and understand the above information:


Thank you in Advance :) Please text, email or DM to book an appointment youngascensionhypnosis@gmail.com
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