HYPNOSIS QUESTIONNAIRE
Please Fill Out This Form Completely
Full Name
*
First Name
Last Name
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Were you referred to me?
*
Yes
No
If yes, who referred you?
*
Have you been diagnosed by a medical professional with any of the following? (check all that apply)
*
Major clinical depression
Bipolar Disorder
Schizo-Affective Type Disorders
Borderline Personality Disorder
None of the above
I understand that hypnosis sessions do not constitute counseling or therapy.
*
I understand
What issue are you interested in resolving?
*
How has this impacted your life in the past? (missed events, relationships, money, etc)
*
How is this issue impacting your life right now?
*
How long have you been affected by this issue?
*
On a scale of 1 10, how committed are you to resolving this problem?
*
How does it make you feel when you think about letting this go once and for all?
*
Once I have approved your application, I will send you an email with a link to schedule your appointment.
*
Understood!
Submit
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