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Intake Survey
Some questions are optional but may increase effectiveness of session
First Name
Email
*
Phone number
*
I am over 18
*
I am over 18
yes
What do you want to work on?
Are you more analytical, or more intuitive?
Are you more analytical, or more intuitive?
0
1
2
3
4
5
6
7
8
9
10
more analytical
equal amounts
more intuitive
Do you have any important spiritual or religious beliefs or systems? Please describe
Your most important 'modality' is probably-
Your most important 'modality' is probably-
sight
sound
touch
taste
smell
other
Untitled checkboxes field
yes
no
Are you currently experiencing or being treated for any of the following
*
Are you currently experiencing or being treated for any of the following
Severe depression
Active suicidal thoughts
Psychosis or schizophrenia
PTSD or unresolved trauma
Bipolar disorder
Substance dependence
None of the above
I understand the practitioner is not a licensed medical professional, and the hypnosis services provided are not intended to be medical, psychological, or psychiatric treatment.
*
I understand the practitioner is not a licensed medical professional, and the hypnosis services provided are not intended to be medical, psychological, or psychiatric treatment.
acknowledged
I don't understand
I consent to participate in a guided hypnosis session and may stop at any time.
*
I consent to participate in a guided hypnosis session and may stop at any time.
yes
I understand that I am responsible for my own well-being and choices
*
I understand that I am responsible for my own well-being and choices
yes
Anything else you'd like me to know
Signature
*
Signature
Today's Date
*
Submit