MTU Hypnosis - Sports Intake Form

MTU Hypnosis - Sports Intake Form
Name*
Home Phone
Format: (000) 000-0000.
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
E-mail*
example@example.com
Address*

3.Address

Street Address Line 2

CityState / Province

Zip
Emergency Contact*
Phone*
Format: (000) 000-0000.
Age*
Birthdate*

MonthDayYear
Date
YesNo
Indicate any current health problems - any medications currently taking
YesNo
YesNo
YesNo
In what sport are you seeking improvement?*
Are you a professional or amateur athlete?*
Specify how much time you physically practice for this sport.*
In the area of athletics, where do you need improvement? What specifically - is the problem?*
What is your ultimate athletic goal?*
What previous efforts, if any, have you taken to solve this issue?*
What is your most difficult emotion right now?*
What has been your proudest moment in this sport?*
If you have ever been hypnotized - indicate private or group/purpose/result?
If you have any fears, concerns, or questions about hypnosis — please describe*
YesNo
YesNo
Provider Name
Phone
Format: (000) 000-0000.
How did you find MTU Hypnosis?*
Effectiveness ( your results )Service ( how we respond to your needs )Time ( how fast you get results )Affordable ( what we charge )
List your e-mail address if you are interested in receiving our e-newsletter
example@example.com
What 3-5 positive benefits are you likely to enjoy by eliminating your problem?

Example: I am more relaxed and at ease even when dealing with stressful situations.
a*
b*
c*
d
e
AlcoholismAngerAnxiousBed WettingCancer/Chemo/RadiationDrug AddictionFear of Flying/HeightsFeeling OverwhelmedGagging ReflexGamblingHabit ControlHigh Blood PressureIBSImproved ConcentrationInfertilityInsomniaJealousyJob Interview AnxietyLearning/ADDMedical/Dental ProceduresMemory ImprovementMigrainesMotivationNail Biting/PickingNervous StomachNervous TicsOCDOrganizational SkillsOver-Healing/ScarringPain ManagementPanic AttacksPerformance AnxietyPre/Post SurgeryProcrastinationPTSDPublic SpeakingRelationship IssuesSalesSelf ConfidenceSkin ProblemsSmoking CessationSports ImprovementStress ManagementStutteringTeeth Grinding/Jaw ClenchingTension HeadachesTest Taking/Study HabitsTime ManagementTobacco ChewingVapingVertigoVisualizationWartsWeight ControlNONEOther
First & Last Name*
Signature*

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Date*

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Date
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