Hypnotherapy Intake Form

See Release Waiver and Booking Policy

Option to Download a Word Interactive Form

Hypnotherapy/NLP Intake Form

This intake is important and will be closely read. A well completed form is required to be appropriate to receive hypnotherapy sessions. The more you put into the process, the more you get out of it.

First name

Last name

Phone Number

1) Have you experienced NLP, hypnosis or hypnotherapy? Describe.

2) What issues do you want to focus on now? What issue is your priority?

3) What old behaviors do you want to stop doing?

What new behaviors do you want to start doing?

4) What old emotions & thoughts do you want to change?

What new emotions & thoughts do you want to experience instead?

5) What success have you had in the past with these or related issues?

What blocks have you had with this issues? Do you know a cause?

6) What beneficial results could come from dealing with this priority issue, and having these new behaviors emotions and thoughts?

7) Summarize what would you like to tell your subconscious, or what you feel your wise subconscious could tell you.

8) For Online Sessions; Do you have a) a headset with an inbuilt microphone, b) a camera that captures your face and upper body with good light, c) a solid device and wifi that's stable for 90+ minutes? These are all required.

9) Do you have any questions?

10) What outcomes would you like to get after the sessions?

Can you attend three to five personal sessions, once a week for three to five weeks?

Do you require Donation Based Sessions? Why?

Do you agree with our RELEASE, WAIVER OF LIABILITY, AND BOOKING POLICY AGREEMENT

Yes

Signature

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Hypnotherapy Intake Form

See Release Waiver and Booking Policy

Option to Download a Word Interactive Form

Hypnotherapy/NLP Intake Form

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