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.
Accept Texting?
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
Are you under a doctor’s care now?
Indicate any current health problems - any medications currently taking
Do you wear contact lens?
Dentures?
Do you have light sensitive epilepsy?
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?
If yes, are you currently receiving treatment or counseling?
Provider Name
Phone
Format: (000) 000-0000.
How did you find MTU Hypnosis?
Select the most important element in deciding to use our services.
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.

Other
First & Last Name
Signature
Date

MonthDayYear
Date
Should be Empty: