Client Questionnaire - Please Share About Yourself
Your Quantum Success Hypnotherapy session will be designed to match you, your experiences, your beliefs, and your needs. If do not feel inspired to complete this form online, no worries! We will interview you to gather this important information during a Quantum Success Hypnosis planning session.
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you learn about Orchard Human Services and Quantum Success Hypnosis?
Teach Us All About You
Share details about yourself to help us personalize your sessions.
Preferred Nickname
Preferred Pronouns
Explain important things that you want us to know to support your session: Such as Relationship Status; Living Situation; Whom You Live With; Business, Career, Employment, Education; Financial Situation; Gender Identity; Sexual Orientation, Hobbies or Special Interests; Important People In Your Life etc.
Age
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Texting Number
Please enter a valid phone number.
Do you give us permission to text and email you to schedule and share other information?
Yes
No
Other - Please explain your communication preferences in the box below. Note that without your permission, we do not have a way to contact you to schedule.
Please explain your communications preferences regarding phone, text, and email.
Time Zone
Your general availability for sessions (days/times)
Goals and Desired Outcomes
Help us understand your intentions and what you hope to achieve.
What is your primary reason for seeking hypnotherapy?
Are there any specific challenges or issues you'd like to address?
How will you know if your hypnotherapy sessions have been successful?
Do you have any secondary goals or areas of interest?
Background and History
Share relevant background to help us personalize your experience.
Have you had prior hypnotherapy experience?
Yes
No
Please describe any medical or mental health conditions we should be aware of.
Are you currently taking any medications? If yes, please specify.
On a scale of 1-10, how would you rate your current stress level?
1 (Very Low)
1
2
3
4
5
6
7
8
9
10 (Very High)
10
1 is 1 (Very Low), 10 is 10 (Very High)
What are your main stress triggers?
Do you currently practice mindfulness, meditation, or other relaxation techniques? If yes, please describe.
Your Beliefs
Share your beliefs and perspectives to help us tailor your sessions.
What are your philosophical or personal beliefs about life, death, and the soul?
What are your spiritual and/or religious beliefs about life?
What types of hypnotherapy are you interested in?
Change habit or behavior
Process and heal trauma
Overcome fear or anxiety
Reduce or eliminate addiction
Discover my life's purpose
Increase my life satisfaction
Recall a forgotten event from my past
Past-life regression
Between-life regression
Something else (explain below)
Explain "Something Else" from above
Expectations and Preferences
Tell us about your preferences and expectations for your sessions.
What are your expectations for your hypnotherapy sessions?
Would you like your session to be recorded? NOTE - sometimes technical issues prevent recording.
Yes
No
Do you have any style preferences for your sessions (for example, tone, pace, or approach)?
Is there anything else you'd like us to know before your session?
Thank you for sharing your information!
We will reach out to schedule your Quantum Success Hypnosis services.
Quantum Success Hypnotherapy services are brought to you by a collaboration between Orchard Human Services, Inc. and PNE Institute, LLC.
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Copyright 2025 PNE Institute, LLC. All rights reserved.
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