EPIC Custom Hypnotic Recording Input Form
Please fill out the information below with as much detail as possible to ensure the most effective version of your hypnotic recording. When you have completed this form, you will see a link to schedule a 1 hour phone call to ensure we have the information needed and clearly understood. Once the recording is created (as an .mp3 file, a standard type of music file), it will be uploaded to a cloud server and you will receive an email with a link to download the file to whatever devices you would like to use to listen to it. We encourage you to listen daily for at least a few weeks to allow the hypnotic reprogramming to fully take hold in your subconscious, resulting in the most effective and efficient way to experience the desired change(s). You will also receive a follow up email that includes a link to schedule additional sessions, which use different protocols, to increase the positive and lasting effects of the change(s) you are looking for.
Name (what you prefer to be called)
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First Name
Last Name
Email
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This is where the link to your recording will be sent.
Phone Number
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Please enter a valid phone number in case any additional information is needed to create your recording.
Birth Year
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Gender pronouns
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He/him
She/her
They/them
How did you hear about us?
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Online Search
Online Ad
Social Media post
Referred by friend/family
Referred by Health Professional
Referred by Organization
Other
How would you prefer to do your call to discuss this form with the hypnotherapist/hypnocoach (a Zoom link was included in the confirmation email when you booked the call, but isn't needed if you prefer to do it with a regular phone call, in that case we will just call the phone number above)?
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Secure video call (Zoom)
Regular phone call (voice)
What is the name of the friend/family/health professional/organization that referred you?
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Do you have any significant hearing loss (if yes, the volume for the background music in your recording will be reduced significantly)?
Yes
No
What type of setting/scene would you find relaxing/peaceful?
This will be used to give your conscious mind something pleasant to focus on (e.g. sunset on the beach, morning in the mountains, etc.)
Your recording will by approximately 30 minutes long, what is the best description of when you'll most likely be able to listen to it?
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Sometime during the day, I'd like it to bring me back to my full waking consciousness at the end
As I'm going to sleep, I'd love to be able to drift off to sleep during or immediately after and stay asleep
I can't dedicate 30 minutes of my day on a regular basis and can't listen in bed, so I need one I can listen to during my commute / while working or doing something else
Please rate your readiness for the change you're looking for.
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1 - it would be nice but I'd be ok without it
2 - it will make my family/friends feel better / get them off my back
3 - I just realized I'd like to make this change
4 - this change is very important to me
5 - I want this change to happen before it gets so bad it feels impossible to change
6 - I really want this change so I can be happier
7 - I want this change badly, I'm sick and tired of how things have been
8 - I really need this change, the way things are without it is exhausting
9 - if this doesn't change soon, I will grow increasingly frustrated and hopeless
10 - if this doesn't change soon, my health will suffer
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What category of change are you looking for?
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Start a new habit
End a bad habit
Change a mindset / belief
Resolve pain or dis-ease
Other
When did this habit start for you?
How long have you been dealing with this issue?
Describe (in detail) what you are wanting to change/achieve with this recording.
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What have you tried already to achieve this change that hasn't worked for you (and indicate if anything has at least helped some)?
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Explain anything that seems to make this issue worse / more intense for you.
Why do you think you haven't been able to achieve this change on your own? (What seems to be getting in the way / what do you need more of to be able to make the change successful)
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What are you concerned will happen in your life if this change does NOT happen?
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Indicate any emotions that you feel about life before (without) the change(s) you want.
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Angry
Annoyed
Anxious
Ashamed
Bewildered
Bored
Bothered
Concerned
Confused
Depressed
Desperate
Disappointed
Discouraged
Disgusted
Disoriented
Drained
Embarrassed
Envious
Exhausted
Fearful
Fed up
Frustrated
Furious
Grumpy
Guilty
Helpless
Hesitant
Hopeless
Horrified
Hostile
Hurt
Impatient
Insecure
Irritated
Jealous
Lonely
Lost
Miserable
Moody
Nervous
Numb
Overwhelmed
Pessimistic
Regretful
Reluctant
Resentful
Sad
Scared
Sensitive
Shy
Sickened
Stressed
Surprised
Suspicious
Tense
Terrified
Tired
Uncertain
Uncomfortable
Unhappy
Unsafe
Unsatisfied
Upset
Vulnerable
Worried
Other
Indicate which of these self-limiting beliefs you identify with (if any)
Alone
Bad
Defective
Different
Helpless
Hopeless
In Danger
Not good enough
Not seen
Out of Control
Powerless
Stupid
Ugly
Unable to express myself
Unlovable
Unsafe
Unwanted
Unsure (always wrong)
Worthless
Other
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Which of these feelings best describe how you want to feel when you achieve this change (try to select at least 10, more if you can)?
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Accomplished
Adventurous
Affectionate
Alive
Amazed
Appreciative
Assured
Beautiful
Bold
Brave
Calm
Capable
Centered
Comfortable
Compassionate
Confident
Content
Curious
Delighted
Driven
Eager
Ecstatic
Encouraged
Energetic
Engaged
Enthusiastic
Excited
Fascinated
Free
Fulfilled
Glad
Grateful
Happy
Hopeful
Impressed
Inspired
Intelligent
Interested
Intrigued
Involved
Joyful
Lively
Marvelous
Motivated
Optimistic
Peaceful
Playful
Pleased
Positive
Proud
Relaxed
Relieved
Respected
Safe
Satisfied
Strong
Surprised
Talented
Thankful
Thrilled
Trusting
Understood
Other
Briefly explain any event(s) or date(s) coming up that you want this change (or at least significant progress) by.
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Include when and what you would like to be different by then.
Describe 3 or more ways that your life will be different when this change happens.
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Please share anything else you think would be helpful for us to know in order to create the most effective hypnotic recording for you.
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