Transformational Hypnosis 1:1
✨20min Consult Call✨1.5hours Hypnosis session ✨post-session Transformational Hypnosis recording ✨28 day follow up and WhatsApp support. All information will be kept strictly confidential except that which I am legally obliged to report, such as a threat of injury to yourself or others. If you are uncomfortable in any way with any of these questions, feel free to skip them. Please be aware that the more you can tell me about yourself, the more I may be of assistance to you. Feel free to go into detail about any issue you wish me to know about you, or to help you with.
Name
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First Name
Last Name
Instagram Handle
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Email Address
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Marital status
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single
partnered
married
divorced
widowed
other
Current Occupation?
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Do you enjoy your work?
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Have you experienced Hypnosis before?
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Yes
No
Have you ever needed to work with mental health professionals? If yes, please provide further information.
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Do you have any current health problems? If so, please provide further details of conditions and treatment
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List any medications you are currently taking, the dosage and side effects for you
Please list any fears, phobias or compulsive tendencies
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Please list any other conditions occurring in your life that you believe are negatively affecting you in any way, or provide details of your concerns, needs or fears
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How would you like Hypnotherapy to help you?
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Sometimes we have a few problems to resolve. If you could narrow it down, which one is more important to work with in our Hypnotherapy session and why?
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Now, imagine yourself without this problem. How would your life be different?
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Would you describe yourself as an analytical person? Yes/No
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What (if anything) would you like to do better in your life?
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Are you currently experiencing any of the following?
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Nervousness
Inability to relax
Sleeplessness
Depression
Nail biting
Nightmares
Sexual Dysfunction
Compulsive Tendencies
Teeth Grinding
Poor Health
Alcohol Abuse
Drug Abuse
Cigarette Smoking
Compulsive Overeating
Self Harm
Serious Eating Disorder
Inability to focus attention
Co-Dependency
Marital Problems
Recent Divorce
Childhood Trauma
Illness or death of a loved one
Lack of energy
Low self esteem
ADD or ADHD
Abusive home situation
PTSD
Abusive work situation
Other
Please list your two favourite places in order of preference
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How do you like to relax?
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What are your two most important lifetime goals?
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List your favourite hobbies
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What is your greatest dream for yourself?
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Is there anything else that you would like to share with me?
I hereby authorise Ina Eremeev to use Hypnosis Techniques on me for the purposes outlined in this form, and for future purposes that I may request. I understand that Hypnosis Therapy is not a medical procedure and that no medical benefits are being offered to me. I understand that the success of Hypnosis Therapy depends on my ability to relax, and my desire to create change in myself. I understand that because the results of the session depend on my own serious participation, Ina Eremeev, cannot offer any guarantee of the success of my treatment. I am aware however, that she will do everything reasonable in her ability to ensure my success.
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I agree
I disagree
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