Blue Hut Healing intake form

1
What's your name?* This field is required.
First Name
Last Name
2
Which treatment are you interested in?* This field is required.
Please Select
Please Select
Hypnoslimmer
Hypnotherapy
Reflexology
Reiki
3
Have you ever had this type of treatment before?* This field is required.
YESNO
4
How long ago did you last have it?* This field is required.
5
How did it go for you?* This field is required.
6
What is the main reason you are interested in this specific type of treatment?* This field is required.(As opposed to other types of treatment)
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7
What are the main benefits or outcomes you are looking for?* This field is required.
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Ok
8
What impact would achieving these have on your life?* This field is required.
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Ok
9
What impact would not dealing with these issues have on you?* This field is required.
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10
What has prompted you to seek treatment at this particular moment in your life?* This field is required.
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11
How did you hear about me?* This field is required.
12
Have you ever been diagnosed with OCD, NPD, Bipolar Disorder, Schizo-Affective type disorders, or Borderline Personality Disorder?* This field is required.Not: Hypnosis sessions do not constitute counseling or therapy and are not appropriate for issues related to these diagnoses.
Please Select
Please Select
Yes, I have had one of these diagnoses
No, I have not had one of these diagnoses
13
Please include any other information that you feel may help us achieve your desired outcome.* This field is required.
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Ok
14
What's your email address?* This field is required.
example@example.com
15
What's your phone number?* This field is required.
Should be Empty: