MTU Hypnosis - Sports Intake Form

MTU Hypnosis - Sports Intake Form
Name*
Home Phone
Cell*
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Accept Texting?*

YesNo
E-mail*
example@example.com
Address*

3.Address

Street Address Line 2

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Emergency Contact*
Phone*
Age*
Birthdate*

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Are you under a doctor’s care now?*

YesNo
Indicate any current health problems - any medications currently taking
Do you wear contact lens?*

YesNo
Dentures?*

YesNo
Do you have light sensitive epilepsy?*

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*
Do you know anyone personally who has used hypnosis to improve or change his or her life?*

YesNo
If yes, are you currently receiving treatment or counseling?*

YesNo
Provider Name
Phone
How did you find MTU Hypnosis?*
Select the most important element in deciding to use our services.*

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
Where applicable, check the issues you have been dealing with and/or would like to resolve.*

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
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Signature*

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Date*

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