Meaningful Release Benefits Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

YOUR MAIN EMOTIONAL ISSUE (the reason you are seeking help):

How Long have you had this problem?

Please explain in the space below what kind of change you want to make. Be as clear and detailed as you can.

Give 1 to 3 changes in the space below.

Now we would like you to take a few minutes TO DESCRIBE HOW THOSE CHANGES WILL BENEFIT YOUR LIFE. How will these changes affect your life and those around you? For example, you might think about how this change may affect your work life, home life, relationship with others, your spiritual life, how you can be a better role model for others and so on. This information will be very useful in making positive suggestions to you while in hypnosis.

Give 1 to 3 benefits in the space below.

Check the following as it applies to you, and fill in the blank space if appropriate.

I know of a past experience or relationship that could be causing this problem/issue.I am aware of an internal conflict that may be causing part (or all) of my problem/issue.

Note Space:

Is there anything else you would like to discuss or work on in the future together with me?