New Client Intake Form
Please fill out this form to the best of your ability to schedule your free strategy call for our hypnotherapy and counseling services.
Have you used hypnotherapy before? If yes, when?
In detail, why would you like to use hypnotherapy and what issues are you experiencing?
What are the top 3 daily frustrations you experiencing due to your issue(s)?
In detail,What results are you looking to achieve? How will your life change?
Over the next 12 months, what is is costing you by keeping this issue(s)? Emotionally? Financially? Time? Professionally?
Have you sought out other assistance with your issue before? (Counselor, Therapist, Coach, Pastor, Self-Help etc..) And how has that failed?
My therapeutic approach is very different from the traditional psychology paradigm to get you the results you are looking for, and this calls for complete openness, cooperation, and self-accountability. Are you willing to cooperate, be open and take accountability for your change?
Yes or No
On a scale of 1-10, How willing to show up and commitment to your change?
1- Least 10 Greatest
If you qualify, do you have the financial resources to move forward in your transformation?
Yes, I am ready to transform and have the financial resources to move forward
No, I am ready to transform, and I'm willing to find the financial resources
No, I am ready to transform, but need time to acquire the financial resources
No, I am not ready to transform at this moment
Have you been referred from one of my previous clients? If Yes, Client Name
Yes, Client Name or No
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm