hypnotherapy

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Hypnotherapy CUSTOM Tape. Please complete the questions below. Once I receive it, I will review the information and contact you via phone or email with any questions that will assist me in making the best possible hypnotherapy session for you. The questions are designed to provide me with as much information to engage in the cooperation approach to hypnotherapy.
	Name:
	Address:
	City:
	State:	Zip:
	Phone:
	Email:
Do you believe change is possible?		Yes No

Problem or Reason for tape (be as specific as you can):

How you believe this problem or issues began?

How long has this problem or issues been affecting your life?

What goals would you like to reach?

What are your strengths? Please be as lengthy and specific needed.

What works or has worked well in your life?

Do you have any physical or mental illness? If yes, please specify:

Are you currently on any prescription medication?		Yes No

Describe what brings a sense of peace or relaxation for you (for example: the ocean, the mountain, etc. Please be as specific as you can:

Are you religious or spiritual?		Yes No

If yes, please explain

Would you like references to your religion or spiritual views in this tape?		Yes No

What may make you feel uncomfortable (words, phrases, images)?

Any further information that you may feel will be helpful, including fears or concerns about hypnotherapy.

The cost of this 60 minute tape is $125.00 plus $5.00 for shipping and handling.

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