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Intake Form

To book for a full session, please take the time to fill out the information below.

First Name

Email

Last Name

Phone

Address

Age

Emergency Contact Name and Telephone Number

Ocupation

Relationship Status

Medication being taken

Health problems (current and past)

Have you been hypnotized before?

Yes

No

What do you feel is the #1 thing holding you back right now (select all that apply)

Addictions

Drinking

Smoking

Drugs

Gambling

Compulsive Behaviour

Anxiety

Stress

Fears

Phobias

Panic Attacks

Guilt

Relaxation

Eating Problems

Food/Diet

Weight Problems

Anorexia

Bulimia

Exercise

Depression

Confidence

Self Esteem

Motivation

Achieving Goals

Procrastination

Career Issues

Interview Skills

Nerves

Public Speaking

Concentration

Exams

Memory

Driving Skills

Sexual Problems

Fertility

IVF

Conception

Pregnancy

Birth

Pain Control

Sight/Vision

Mobility

Skin Problems

Hair Growth

Relationships

Childhood Problems

Sleep Problems

PTSD

Codependency

Other area of concern, not listed above

If you had to choose ONE, MOST IMPORTANT ISSUE to focus on in your session, what would it be and why?

If you no longer struggled with this issue, how would it impact your life?

What's your ultimate desire?

Just before you submit your details, please confirm you have read and agree to the waiver document View Waiver

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