Hypnotherapy with Dani
Street Address Line 2
State / Province
Postal / Zip Code
Children? If so, how many?
Have you ever been hypnotized before?
What would you like to accomplish? (Check all that apply)
Earn more money
Find your ideal mate
Regain my sense of taste and/or smell
Past life regression
Be more productive/efficient with work
Get in shape
Help with depression
Help with PTSD
Become more organized
Eliminate fear of failure
Improve public speaking skills
Eliminate bad habits (nail biting, skin picking, hair pulling, etc)
Is there anything else you would like help with?
List your top 3 issues from above, in order of importance.
How do you think your life will be better once you make these changes… personally, professionally, emotionally?
Are you prepared to invest in yourself for effective & long term change?
Have you tried any other methods to resolve these problem?
Why didn’t those methods work for you?
On a scale of 1-10, how coachable are you?
1 - I do what I want
5 - half the time, yes.
10 - a coach’s dream come true
What hobbies or activities do you enjoy? What do you love to do?
Do you consider yourself to be a perfectionist?
Which of the following vacation destinations do you NOT enjoy? (Select all that apply)
I am okay with all of the above
Do you have any current health problems?
Do you follow any religious or spiritual practices? If so, please describe briefly.
Please use the area below to add any further thoughts or information you think may be helpful or relevant in any way.
I have essential oils diffusing in my space. Are there any scents that you are sensitive to?
How did you hear about me?
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