New Customer Registration Form

CLIENT QUESTIONNAIRE

Ron Niederkofler, CHt
ron@directpathhypnosis.com
360-773-1873
FAX 360-953-8650
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Birth Date
Age
Marital Status

Single Married Divorced Widowed
Gender
Number of children
Occupation
Place of Employment
Emergency Contact Name

First Name Last Name
Emergency Contact Phone Number

Area Code Phone Number
Relationship to Emergency Contact
How did you hear about us? *
If referral, who referred you?
Other
If you were referred by a medical professional, do we have your permission to discuss your progress with him/her?

Yes No
Doctor’s Name
Have you ever had a hypnosis session before? Was it a positive experience?
Is there a relationship in your past that may have contributed to this issue?
What would you like to accomplish in your hypnotherapy session/s (what do you realistically expect the end result to be)? Make sure your answer is believable, achievable, and specific.
Please list three of the benefits you expect to gain as a result of making the change that you would make.
List three words that would best describe you after making these changes.

On a scale of 1 – 10, 10 being totally willing, what is your willingness to change?

	1	2	3	4	5	6	7	8	9	10

1 is Not wililng, 10 is Totally willing

List three descriptive words that will no longer apply to you as a result of making these changes.
Now, without thinking about it, quickly list three accomplishments that you are most proud of.
We find it useful to sometimes use a holistic approach (mind-body-spirit) when appropriate. Would you consider yourself a spiritual person? Please describe.
What is it that you like to do to relax?
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