Empowered Hypnotherapy booking form
Welcome .. Thank you for your enquiry ..I look forward to seeing you soon, please answer the following questions with as much detail as you can.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
DOB
-
Month
-
Day
Year
Appointment Request (leave blank if unsure)
Have you ever experienced Hypnosis before ?
If so for what reason ?
Do you believe you were hypnotised ? If so ..how did you know .?
How did that experience go for you ?
Reason for this appointment ...
Are you undergoing any other Medical or Psychological treatment for this issue ? If so with whom ?
Are you currently taking any medication of any kind ? If yes .. what kind and for what reason ?
Do you have any specific questions about hypnosis?
What are you wanting to achieve for yourself at this moment ?
Would you prefer your first free consult be via phone , video chat or in person ?
Submit
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