Contact Information

    Name

    Street

    City

    State

    ZIP

    Daytime Phone

    Evening Phone

    Email

    Preferred Pronoun

    Area of Interest or Challenge

    Weight ReductionStop SmokingReduce StressChange Inhibiting BeliefsRelease Fear or PhobiasImprove Learning SkillsHandle Changes More ComfortablyBuild Confidence/Self EsteemHandle Anger/FrustrationIncrease Creativity MotivationEliminate Sabotaging BehaviorsPain ControlImprove PerformanceAge RegressionOther

    If other, please explain:

    I recognize that my health and wellbeing depend directly on how well I care for myself emotionally, physically, intellectually and socially.
    I recognize that the outcome of my hypnotherapy depends on the acceptance of being personally responsible for myself.
    I am willing to commit to my own healing and improvement.
    I will allow adequate time and enough sessions so that the desired change can happen. I agree to be on time and be prepared to participate in order to achieve a successful outcome.

    Have you ever experienced Hypnosis or NLP before?
    YesNo

    If so, when?

    Purpose:

    Outcome:

    What environments do you find most relaxing?

    Do you have any fears of the following?
    Going up (or down) escalators, stairs, hills or elevator?Drifting or floating?Water, oceans, rivers, pools or lakes?EnvironmentsOther
    If other, please explain:

    Are you currently under medical or psychological care?

    Have you had or are you currently being treated for any ongoing medical or psychological conditions?
    YesNo

    Please explain.

    Please describe any current medications and their side effects:

    Please describe your daily caffeine intake:

    Hypnosis is most effective when in a state of relaxation. Please avoid caffeine for several hours prior to your session.

    Needs Assessment

    Please answer these to the best of your ability. I look forward to working together with you to reach the outcome that you desire!

    1. What would be your best possible experience and outcome using hypnosis?

    2. What would be your evidence that you had achieved your outcome?

    3. What would happen if you get this outcome?

    4. What are the benefits (ex: feelings, rewards, habits retained etc.) of what you have been doing?

    5. Will getting this outcome affect other aspects of your life? (ex: what might you need to give up? What might you need to add? Would you need to fill your time?)

    6. What are the costs of what you’ve been doing?

    7. What has stopped you from accomplishing it?

    Who can I thank for referring you?

    Thank you for taking the time to fill this out.
    The focus of our sessions is helping you get from where
    you are to where you want to be, and the following information will help guide our process. Please do not leave any spaces blank before making an e-submission. Just place an X or an O in any space that you are unsure about. Thank you!

    *Your personal information will never be shared with any outside parties.