Virtual Assistant to get an appointment

1
What's your first name?* This field is required.
first name
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'ia ora na {prenom}, I'm Yvan, the hypnotist.

This virtual assistant will collect information in a secure way and allows you to save 1 session, because I will already know your problem, what you have been through, and your general state in order to establish the best strategy for your upcoming consultation.

Make sure you have about 15 minutes ahead of you to answer the following questions.

The more specific you are in your answers, the more specific I will help you.

The more vague you are in your answers, the more vaguely I will help you 😉
3
Confidentiality

What happens during the consultation will be kept confidential, except in the following cases:

you give me specific permission to disclose information to specific individuals or an institution

in cases of child abuse

in cases of self-destructive behavior or imminent danger to others
in the case of a subpoena or court order.

in the case of a subpoena or court order.

All information shared is confidential and subject to confidentiality.
4
Was this consultation recommended by a physician or therapist?* This field is required.
YESNO
5
I authorize Yvan Amar to discuss my case with:
name of referring physician or therapist
6
The investment is only 15,000 XPF (125.70 EUR) per session (2 hours).

For children under 13 yo, it's 7,500 XPF (62.85 EUR) per sesson (1 hour).

Payment is made in cash at the end of each in-person consultation.

For remote consultations via phone, Skype™ or Zoom™, payment is made before each session by credit card via Paypal™, or bank transfer (local or int'l in your currency).
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Each appointment is a time slot that I reserve in my schedule and during which I am available for you, {prenom}.

Therefore, any session "forgotten" or not cancelled 24 hours in advance will be considered as due, unless we can reschedule the appointment within the same week.
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Do you agree to the pricing, rescheduling and cancellation policy? * This field is required.
Yes, I accept
9
{prenom}, describe to me your "issue" to the best of your knowledge:* This field is required.if you have more than one, focus the following questions on the main "problem" only
detailed description of the presented problem
0/1111
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When and under what circumstances did this "issue" started, {prenom}?* This field is required.
0/1111
11
What impact has this "issue" had in your life?* This field is required.what consequences?
0/1111
12
What have you done in the past to address this issue and what were the results ?* This field is required.
0/1111
13
What aspect, specifically, of your "issue" leads you to seek help today, {prenom}?* This field is required.
0/1111
14
What bad things would happen further into the future if you wouldn’t change?* This field is required.use your imagination, {prenom}
0/1111
15
Ok, and what do you think needs to happen for you to change?* This field is required.of course you have an idea
0/1111
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Until today {prenom}, What has been stopping you from making the changes you want?* This field is required.
0/1111
17
Do you associate any of the following emotions with your "issue"?if yes, check only the most relevant
abandonment
boredom
fear
anger
anxiety
guilt
shame
sadness
stress
frustration
loss
depression
18
What good things will happen to you in the short term and long term when you get the change, {prenom}?* This field is required.
0/999
19
Name 3 hobbies, passions, or areas in your life that you enjoy and are good at:* This field is required.
excitement number 1
excitement number 2
excitement number 3
20
Excellent {prenom}! Now please name 2 times in your life when you have accomplished something significant, that you thought you wouldn’t be able to accomplish* This field is required.positive stuffs for you
accomplishment number 1
accomplishment number 2
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Oh by the way, have you ever been hypnotized before?* This field is required.
YESNO
22
Great! By whom?* This field is required.
23
And when was that?* This field is required.
24
What are the results you got?* This field is required.
0/999
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{prenom}, do you consider yourself a good imaginer?* This field is required.
YESNO
26
During the last 4 weeks {prenom}, how much have you been bothered by any of the following problems?* This field is required.select the best answer
not bothered
bothered a little
bothered a lot
a) Stomach pain
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b) Back pain
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c) Pain in your arms, legs, or joints (knees, hips, etc.)
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d) Menstrual cramps or other problems with your periods
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e) Pain or problems during sexual intercourse
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f) Headaches
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g) Chest pain
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h) Dizziness
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i) Fainting spells
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j) Feeling your heart pound or race
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k) Shortness of breath
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l) Constipation, loose bowels, or diarrhea
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m) Nausea, gas, or indigestion
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a) Stomach pain
b) Back pain
c) Pain in your arms, legs, or joints (knees, hips, etc.)
d) Menstrual cramps or other problems with your periods
e) Pain or problems during sexual intercourse
f) Headaches
g) Chest pain
h) Dizziness
i) Fainting spells
j) Feeling your heart pound or race
k) Shortness of breath
l) Constipation, loose bowels, or diarrhea
m) Nausea, gas, or indigestion
not bothered
Row 0, Column 0
bothered a little
Row 0, Column 1
bothered a lot
Row 0, Column 2
not bothered
Row 1, Column 0
bothered a little
Row 1, Column 1
bothered a lot
Row 1, Column 2
not bothered
Row 2, Column 0
bothered a little
Row 2, Column 1
bothered a lot
Row 2, Column 2
not bothered
Row 3, Column 0
bothered a little
Row 3, Column 1
bothered a lot
Row 3, Column 2
not bothered
Row 4, Column 0
bothered a little
Row 4, Column 1
bothered a lot
Row 4, Column 2
not bothered
Row 5, Column 0
bothered a little
Row 5, Column 1
bothered a lot
Row 5, Column 2
not bothered
Row 6, Column 0
bothered a little
Row 6, Column 1
bothered a lot
Row 6, Column 2
not bothered
Row 7, Column 0
bothered a little
Row 7, Column 1
bothered a lot
Row 7, Column 2
not bothered
Row 8, Column 0
bothered a little
Row 8, Column 1
bothered a lot
Row 8, Column 2
not bothered
Row 9, Column 0
bothered a little
Row 9, Column 1
bothered a lot
Row 9, Column 2
not bothered
Row 10, Column 0
bothered a little
Row 10, Column 1
bothered a lot
Row 10, Column 2
not bothered
Row 11, Column 0
bothered a little
Row 11, Column 1
bothered a lot
Row 11, Column 2
not bothered
Row 12, Column 0
bothered a little
Row 12, Column 1
bothered a lot
Row 12, Column 2
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During the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.select the best answer
not at all
several days
more than half the days
nearly everyday
1) Feeling nervous anxiety or on edge
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2) Not being able to stop or control worryin
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3) Worrying too much about different things
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4) Trouble relaxing
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5) Being so restless that it is hard to sit still
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6) Becoming easily annoyed or irritable
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7) Feeling afraid as if something awful might happen
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1) Feeling nervous anxiety or on edge
2) Not being able to stop or control worryin
3) Worrying too much about different things
4) Trouble relaxing
5) Being so restless that it is hard to sit still
6) Becoming easily annoyed or irritable
7) Feeling afraid as if something awful might happen
not at all
Row 0, Column 0
several days
Row 0, Column 1
more than half the days
Row 0, Column 2
nearly everyday
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not at all
Row 1, Column 0
several days
Row 1, Column 1
more than half the days
Row 1, Column 2
nearly everyday
Row 1, Column 3
not at all
Row 2, Column 0
several days
Row 2, Column 1
more than half the days
Row 2, Column 2
nearly everyday
Row 2, Column 3
not at all
Row 3, Column 0
several days
Row 3, Column 1
more than half the days
Row 3, Column 2
nearly everyday
Row 3, Column 3
not at all
Row 4, Column 0
several days
Row 4, Column 1
more than half the days
Row 4, Column 2
nearly everyday
Row 4, Column 3
not at all
Row 5, Column 0
several days
Row 5, Column 1
more than half the days
Row 5, Column 2
nearly everyday
Row 5, Column 3
not at all
Row 6, Column 0
several days
Row 6, Column 1
more than half the days
Row 6, Column 2
nearly everyday
Row 6, Column 3
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GAD-7
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During the last 4 weeks {prenom}, have you had an anxiety attack (suddenly feeling fear or panic)?* This field is required.
YESNO
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Has this ever happened before?* This field is required.
YESNO
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Do some of these attacks come suddenly out of the blue (that is, in situations where you don’t expect to be nervous or * This field is required.
YESNO
32
Do these attacks bother you a lot or are you worried about having another attack?* This field is required.
YESNO
33
During your last bad anxiety attack, did you have symptoms like shortness of breath, sweating, or your heart racing, pounding or skipping?* This field is required.
YESNO
34
During the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.select the best answer
not at all
several days
more than half the days
nearly everyday
a) Little interest or pleasure in doing things
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
b) Feeling down, depressed, or hopeless
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c) Trouble falling or staying asleep, or sleeping too much
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d) Feeling tired or having little energy
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e) Poor appetite or overeating
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f) Feeling bad about yourself — or that you are a failure or have let yourself or your family down
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Row 5, Column 3
g) Trouble concentrating on things, such as reading an article or watching a video
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Row 6, Column 3
h) Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or estless that you have been moving around a lot more than usual
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Row 7, Column 3
i) Thoughts that you would be better off dead of or hurting yourself in some way
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Row 8, Column 2
Row 8, Column 3
a) Little interest or pleasure in doing things
b) Feeling down, depressed, or hopeless
c) Trouble falling or staying asleep, or sleeping too much
d) Feeling tired or having little energy
e) Poor appetite or overeating
f) Feeling bad about yourself — or that you are a failure or have let yourself or your family down
g) Trouble concentrating on things, such as reading an article or watching a video
h) Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or estless that you have been moving around a lot more than usual
i) Thoughts that you would be better off dead of or hurting yourself in some way
not at all
Row 0, Column 0
several days
Row 0, Column 1
more than half the days
Row 0, Column 2
nearly everyday
Row 0, Column 3
not at all
Row 1, Column 0
several days
Row 1, Column 1
more than half the days
Row 1, Column 2
nearly everyday
Row 1, Column 3
not at all
Row 2, Column 0
several days
Row 2, Column 1
more than half the days
Row 2, Column 2
nearly everyday
Row 2, Column 3
not at all
Row 3, Column 0
several days
Row 3, Column 1
more than half the days
Row 3, Column 2
nearly everyday
Row 3, Column 3
not at all
Row 4, Column 0
several days
Row 4, Column 1
more than half the days
Row 4, Column 2
nearly everyday
Row 4, Column 3
not at all
Row 5, Column 0
several days
Row 5, Column 1
more than half the days
Row 5, Column 2
nearly everyday
Row 5, Column 3
not at all
Row 6, Column 0
several days
Row 6, Column 1
more than half the days
Row 6, Column 2
nearly everyday
Row 6, Column 3
not at all
Row 7, Column 0
several days
Row 7, Column 1
more than half the days
Row 7, Column 2
nearly everyday
Row 7, Column 3
not at all
Row 8, Column 0
several days
Row 8, Column 1
more than half the days
Row 8, Column 2
nearly everyday
Row 8, Column 3
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PHQ-9
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PHQ-15
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How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?* This field is required.
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
38
{prenom}, please describe any significant physical or psychological treatment or medication you have received in the past 12 months.* This field is required.Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
please write "no medication" if it doesn''t apply to you.
0/1111
39
Have you ever been hospitalized for illness or surgery?* This field is required.
0/1111
40
So, {prenom}, what is your best availability for the appointment(s)?* This field is required.
ideally
possible
impossible
Monday am
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Monday pm
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Row 1, Column 2
Tuesday am
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Tuesday pm
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Wednesday am
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Row 4, Column 2
Wednesday pm
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Row 5, Column 2
Thursday am
Row 6, Column 0
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Row 6, Column 2
Thursday pm
Row 7, Column 0
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Row 7, Column 2
Friday am
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Friday pm
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Monday am
Monday pm
Tuesday am
Tuesday pm
Wednesday am
Wednesday pm
Thursday am
Thursday pm
Friday am
Friday pm
ideally
Row 0, Column 0
possible
Row 0, Column 1
impossible
Row 0, Column 2
ideally
Row 1, Column 0
possible
Row 1, Column 1
impossible
Row 1, Column 2
ideally
Row 2, Column 0
possible
Row 2, Column 1
impossible
Row 2, Column 2
ideally
Row 3, Column 0
possible
Row 3, Column 1
impossible
Row 3, Column 2
ideally
Row 4, Column 0
possible
Row 4, Column 1
impossible
Row 4, Column 2
ideally
Row 5, Column 0
possible
Row 5, Column 1
impossible
Row 5, Column 2
ideally
Row 6, Column 0
possible
Row 6, Column 1
impossible
Row 6, Column 2
ideally
Row 7, Column 0
possible
Row 7, Column 1
impossible
Row 7, Column 2
ideally
Row 8, Column 0
possible
Row 8, Column 1
impossible
Row 8, Column 2
ideally
Row 9, Column 0
possible
Row 9, Column 1
impossible
Row 9, Column 2
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If this schedule does not fit your availability at all, please let me know the desired days and times, and I will do my best to find an arrangement.
42
{prenom}, would you please write your full name?* This field is required.
First name
other names
last name
43
What gender do you consider yourself to be, {prenom}?* This field is required.
male
female
other
44
et vous êtes né quand?
jour
mois
année
45
and what's your birthdate ?* This field is required.type your date of birth
46
What is your main occupation, or your job title?* This field is required.what do you do most of your day?
also specify in which sector of activity (e.g. tourism)
47
I would also like your e-mail so we can write each others 🙂* This field is required.check its validity, no space
48
and a phone number for the confirmation?* This field is required.
digits only
49
and a postal address for billing?* This field is required.
street
(P.O box ?)
city / town
island
ZIP code
French Polynesia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
country
50
Notice and conditions
NOTE : The terms Hypnotist / Hypnotherapist / Consultant are used interchangeably in the following document.

I have been informed by Yvan Amar, the Hypnotist, of the scope of the practice of hypnosis, and I fully agree to receive a hypnosis session. I already know that human behavior can not be guaranteed, and that my success depends on many factors, including my attitude, motivation, cooperation, and participation in the sessions. Hypnosis and Hypnotherapy are not intended to replace medical, psychological or psychiatric treatment.

I also understand that the Hypnotist / Hypnotherapist does not treat, prescribe or diagnose a medical condition. Yvan Amar can not recommend that a client stop seeing a health professional, or taking medication, or treatments that have been prescribed by a health professional. I understand that the Consultant is a facilitator of hypnosis and hypnotherapy.

I know that I am free to end all sessions at any time. I gave my permission to participate in each session to the best of my abilities. I have accurately provided information about my past as requested by the Hypnotist / Hypnotherapist. I understand that the confidentiality between Yvan Amar and me regarding my sessions will be honored. This same confidentiality is respected when the customer is a minor under 18 years old.
51
Do you understand and agree to the previous notice and conditions?* This field is required.
Yes, I understand and accept the notice and conditions presented
52
Can I contact you to follow-up regarding the presented issue(s) ?* This field is required.I prefer to ask in advance 🙂
YESNO
53
Finally, {prenom}, write here whatever you think is important to tell me before we start.
54
By signing digitally below, I, {prenom}, certify that the information provided to this virtual assistant is true and complete to the best of my knowledge.* This field is required.Sign with the mouse, a stylus, or your fingers, it's perfect :)
Clear
55
{prenom}, are you under 18 yo?* This field is required.
YESNO
56
Since you are under 18 years of age, {prenom}, I need the Name and Signature of a legal guardian, that's mandatory* This field is required.
fisrt name
last name
relationship to the participant ?
57
Thanks, now please sign under for {prenom}:* This field is required.Sign with the mouse, a stylus, or your fingers, it's perfect :)
Clear
58
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