CONSULTATION REQUEST
Fill out this form completely to request a free consultation.
Name
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First Name
Last Name
Email
*
example@example.com
Date
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-
Month
-
Day
Year
Date
Were you referred to me?
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Yes
No
If yes, who referred you?
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If not, how did you hear about me?
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Have you been diagnosed by a medical professional with any of the following (check all that apply)?
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Major clinical depression
Bipolar disorder
Schizo-affective type disorders
Borderline personality disorder
None of the above
I have NOT been diagnosed with majorclinical depression, Bipolar Disorder,Schizo-Affective type disorders, orBorderline Personality Disorder. I understand that these hynosis sessionsdo not constitute counseling or therapy.
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I understand.
What issue are you interested in resolving?
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How has this impacted your life in the past? (Examples: fear, missed events, relationships, money, unwanted habits, etc.)
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How is this issue impacting your life right now?
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On a scale of 1-10, how committed are you to resolving this problem?
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How does it make you feel when you think about letting go once and for all?
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How do you feel about investing in yourself?
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Please list 3 convenient times for a connection call and I will be in touch with you to schedule. Please include your time zone.
Phone Number
*
Please enter a valid phone number.
Anything else you'd like to say?
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