Hypnotherapy with Dani
Intake form
Name
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First Name
Last Name
Phone number
*
Example: XXX-XXX-XXXX
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
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Occupation
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Marital Status
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Married
Single
Divorced
Widow
It’s complicated
Children? If so, how many?
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Have you ever been hypnotized before?
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Yes
No
What would you like to accomplish? (Check all that apply)
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Nutritional support
Hypnobirthing preparation
Earn more money
Find your ideal mate
Heartbreak
Regain my sense of taste and/or smell
Improve relationship/marriage
Be more productive/efficient with work
Imposter syndrome
Get in shape
Reduce anxiety
Reduce stress
Eliminate fear/phobia
Help with depression
Help with PTSD
Stop worrying
Increase self-confidence
Improve focus/concentration
Stop procrastinating
Improve sleep
Become more organized
Eliminate overwhelm
Eliminate fear of failure
Improve public speaking skills
Practice mindfulness/meditation
Tobacco cessation
Anger management
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.
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How do you think your life will be better once you make these changes… personally, professionally, emotionally?
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Are you prepared to invest in yourself for effective & long term change?
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Yes
No
Have you tried any other methods to resolve these problem?
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Yes
No
Why didn’t those methods work for you?
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On a scale of 1-10, how coachable are you?
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1 - I do what I want
2
3
4
5 - half the time, yes.
6
7
8
9
10 - a coach’s dream come true
What hobbies or activities do you enjoy? What do you love to do?
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Do you consider yourself to be a perfectionist?
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Yes
No
Which of the following vacation destinations do you NOT enjoy? (Select all that apply)
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Beach
Mountains
Large cities
Foreign countries
I am okay with all of the above
Do you have any current health problems?
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Do you follow any religious or spiritual practices? If so, please describe briefly.
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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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