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  • Fears, Stress, Anxiety and Sleep Issues Questionnaire

  • The following questionnaire is entirely confidential. The questions and answers within are for the sole purpose of aiding us to assess how to proceed with your sessions.  Because the practitioner needs to be aware of all existing and pre-existing physical and/or psychological conditions, please fill out this form completely and disclose all pertinent information.

  • Confirm Your Contact Details

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  • Share Some Personal Details

  • Date of Birth
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  • Sex

  • All sessions are currently being done online or in person.  Our preferred application is Zoom but we can also connect with you on Facebook or Messenger.

    You will have to have access to this technology.  A laptop or tablet work the best for a session since you will have to be relaxed and not holding your device.  We will need to see your face and your arms during a session.  If you can sit in a comfortable flat backed or lounge chair, that will work the best.  Please make sure you won't be interrupted during a session and that you are in a quiet environment.  Hypnosis takes a great amount of concentration. 

  • Do you have access to:

  • Current Mental & Health Issues

  • Do you have any of the following medical issues? Please check all that apply.
  • Do you have any hearing problems?
  • Are you afraid of or uncomfortable thinking about any of the following?
  • Have any members of your family every suffered from alcohol or drug addiction?
  • Have you ever been in an abusive physical or emotional relationship?
  • Do you usually feel drained at the end of the day?
  • How do you handle speaking your truth to someone?

  • Tell us bit about what you're dealing with.

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  • Since the issues of fears, anxiety, stress and sleep issues are often associated with each other, we would ask you to fill out all the sections that apply to you.  If a section does not apply, then please just leave it blank. 

  • Fears and Phobias

  • Do you have any of the following physical reactions when faced with your fear or phobia? Check all that apply
  • Tell us about any emotional reactions you have. Check all that apply.

  • Anxiety and Stress

    continued...
  • Do you have any of the following physical reactions to stress or anxiety? Check all that apply.
  • Tell us about any emotional reactions you have to stress and anxiety

  • Sleep Issues

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  • What form does your sleep disturbance take?

  • Current Issues

  • Are you currently suffering from any of the following

  • Past Experiences

  • Have you ever been Hypnotized before?

  • Read and Agree to Terms

  • Hypnosis is not a substitute for allopathic, medical or psychotherapeutic treatment.  The hypnosis practitioner, therefore, does not diagnose allopathic, medical or psychological conditions, nor prescribe medical treatments or pharmaceuticals.

    Hypnosis takes a holistic approach to the client's well-being by encouraging the client to live a better and happier life of greater welll-being.  Its goal is to promote and maintain optimum health and is often effective for specific problematic issues.

    I confirm that all the information that I have given on this form is correct and that I have not omitted any key health condition that may impact or interfere with my hypnosis sessions.  I am open and receptive to the process of hypnosis and I am willing to do my part.  I will in no way hold Twin Flame Creations Inc. or any practitioner therein responsible for any unwanted side effects caused by my hypnosis sessions and take sole responsibility for my well-being.

    I also understand that 48 hours notice must be given to cancel or reschedule any appointment or I will be charged for the missed appointment..

  • Payment Information

    You can pay for your sessions by going to our website at www.awakeningangels.ca and use a credit or debit card through PayPal in our store.  We also accept e-transfers and credit cards over the phone.  Please specify your payment choice and we will contact you directly for e-transers and over the phone payment.

  • My payment choice is

  • Protection of personal information in the private sector (Bill 68)

    You have given us personal information.  We shall consider that you consent to our keeping in a file, all information you have already given or may give us, orally, in writing or electronic.  This information will not be shared with anyone else and when disposed of will be shredded.

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