Pre-Consultation Assessment Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Age * Referral Social Media Friend or Family Google Other Do you have any medical conditions I should know about? Please specify. * Do you take any medication for anxiety/depression? * Have you ever been hypnotized before? If yes, please explain: * Have you ever been treated for an emotional issue before? If yes, please explain. * Were there any previous efforts to solve this? If yes, what were the results? * Do you have any fears or phobias? Please explain. * What are you looking to accomplish in our session? What is your goal? * Do you believe you can achieve this goal? * Are you willing to do the work to achieve this change? * On a scale from 1 to 10, how committed are you to doing the work? * What do you wish to release from your life? * What do you wish to gain? * Who will you be once you achieve this goal? * How will your life improve once you achieve this goal? * Would you like to receive my newsletter? Yes, I agree. No Consent: I am willing to be guided through hypnosis, visualizations, and stress reduction processes and techniques for the main purpose of self improvement. I understand that hypnosis is not a substitute for any normal medical care. Additionally, I will consult with my doctor about any medical conditions and continue any current medical regimens and/or consult with my medical doctor for treatment of any old or new illnesses. Yes, I agree. No Signature * Enter Full Name Date MM DD YYYY Any additional information you wish share? Thank you!
