Discovery Call Application
After you submit your application you will be redirected to a scheduling page to book your discovery call.
Name
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First Name
Last Name
Email
*
In the event there is more than one person with the same name, you will be identified using your email address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Were you referred to me?
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Yes
No
If yes, who referred you?
If no, where did you hear about me?
Which healing adventure are you interested in?
Coaching
Hypnosis
Talk
Have you ever been hypnotized before?
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Yes
No
What was the reason you were hypnotized? What was your experience? (If no, enter N/A)
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Please respond if you have been diagnosed with any of the following by checking one of the options below: Major Clinical Depression, Bipolar Disorder, Schizophrenia, Schizoaffective Disorder, or Borderline Personality Disorder. I understand that these hypnosis sessions do not constitute counseling or therapy.
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I have NOT been diagnosed with any of the above diagnoses
I have been diagnosed with one of the listed above diagnoses
Comments or details you would like to provide regarding the above question.
What issue are you interested in resolving?
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In what ways have you struggled in the PAST related to what you are looking to resolve? (missed events, relationships, money, etc.)
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How is this issue currently impacting your life right now?
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On a scale of 1-10 (1 being 1% & 10 being 100% ready), how ready are you to resolve this problem?
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How does it make you feel when you think about resolving and letting go of this issue once and for all?
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Are you willing and able to invest in yourself if working with me feels right to resolve your issue?
YES! I have the resources available to invest in myself to resolve this issue right now
YES! I have access to funds, but might need a payment plan
NO! I don’t have the funds / don’t want to invest in myself to resolve this issue right now
If you're accepted to work with me, how soon can you get started? (Enter specific date or month/year)
Session Benefits
Please list seven of benefits you expect to gain from making the change you would like to make in resolving the issue you listed above. Pick the SINGLE MOST important item if you listed more than one. (If we give the subconscious mind too many things to work on at once, the easiest thing for it to change is nothing at all)
1. Benefit One:
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2. Benefit Two:
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3. Benefit Three:
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4. Benefit Four:
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5. Benefit Five:
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6. Benefit Six:
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7. Benefit Seven:
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Select as many of the following as it applies to you and fill in the blank space if applicable using the text box below.
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1. I often feel that I should be punished for something I once did.
2. I know of a past experience or relationship that could be causing this problem.
3. I am aware of an internal conflict that may be causing part (or all) of my problem)
4. If I get better, I stand to lose.......(use text box below to fill in blank)
5. If I wasn't so much like........, I'd be much happier. (use text box below to fill in blank)
If you selected option 4 and/or 5 above, please write the statement(s) in full sentences, filling in the blank:
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Do you have any questions about hypnosis?
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Are you familiar with Zoom? We will be meeting via the Zoom video web conferencing application - (you will be redirected to schedule a call with after you hit submit)
Yes
No
Submit
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