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!
Please use your *Whole Name* (as well as Social Media Name if that is how you are communicating with me) *
Your answer
Pronouns, Gender Identity & relevant details: *
Your answer
Contact Info *
Email, skype or phone number (for the purpose of following up or connecting for online sessions)
Your answer
Why have you come to Hypnosis? *
Your answer
Are there any boundaries or topics you do NOT wish to touch upon? *
Your answer
Relationship Status: current or previous significant/relevant dynamics or abuse (please include names if relevant): *
Your answer
Do you have children?
Your answer
Please detail any pregnancies, abortions or miscarriages yours or your partner’s (reasons for terminations at the time): *
Your answer
What other Healing Modalities have you sought for these issues and in general? *
Your answer
Have you ever experienced Hypnosis? *
(please detail)
Your answer
Please Describe your Spiritual Beliefs and Practices *
Your answer
Have you any significant accidents/trauma/surgeries: *
Your answer
Please Describe your relationship to recreational drugs and alcohol: *
Your answer
Please detail your history and your family history of mental health struggles depression/anxiety or addiction: *
Your answer
Please detail your relationships with your family/ancestors and intergenerational trauma or mental illness? *
partners, divorce, parents, siblings, children
Your answer
Regarding Visualizations, what is appealing to you *
Required
Do you have a specific place in nature (or otherwise) that feels like your own private paradise? *
Your answer
Any place you feel uneasy or fearful? *
Your answer
Some place or thing that you find peaceful or reassuring *
Required
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
Your answer
Please indicate your pertinent health history & current medications: *
Add your Physician’s Name and Number in case of emergency
Your answer
How did you find Ascension Hypnosis? *
Your answer
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 Email to book an appointment youngascensionhypnosis@gmail.com
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