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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
*
yes
What do you want to work on?
Are you more analytical, or more intuitive?
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1
2
3
4
5
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7
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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-
sight
sound
touch
taste
smell
other
Untitled checkboxes field
yes
no
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.
*
acknowledged
I don't understand
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
*
yes
Anything else you'd like me to know
Signature
*
Signature
Today's Date
*
Submit