20 % ALL INFORMATION ON THIS PAGE IS STRICTLY CONFIDENTIAL Your Full Name: * Describe anything that makes you uncomfortable (Water, Heights, Closed Spaces, Insects, etc): * What issue(s) are you seeking hypnosis for today? * Describe WHEN it / they began and the circumstances: * How has this affected your life and what specifically about your issue is leading you to seek help today? * Describe anything you have tried to resolve this / these issues previously: * Describe what did NOT work: * What lifestyle or attitude changes have helped, or at least been partially successful? * Now that You are About to See Positive Changes in Your Life, List at least SEVEN (7) Positive Benefits that You Want to See in Your Life as a Result of Hypnosis: Because I am Changed, I Will Feel Like... * Because I am Changed, I Will be Able to... * Now that I am Changed, I can... * Because I am Changed, Others will See Me as... * Because I am Changed, I will Know... * Because I am Changed, I will Enjoy... * Because I am Changed, My New Goal is... * What other Positive Changes Do You Want to See in Your Life? (Don't Limit Yourself...Think BIG. * What other issues, either linked or not linked to the presenting issue do you need help with? * Do you experience any of these feelings or associate them with the issue you are seeking hypnosis for? Check all that apply. * Abandonment Anger Anxiety Boredom Concentration or Memory Issues Confidence Issues Tendency to Criticize Embarrassment Fear Frustration Grief Irritability Loneliness Loss Mood Swings Sadness Shame Sleep Trouble Other If "Other", Please describe: Do you now or have you in the past practiced Relaxation Techniques Like Yoga, Meditation or some other method? * YES NO Do You Sing, play a musical instrument, paint or engage in some other creative interest? * YES NO When you become interested in watching TV, a movie or working on the computer, do you sometimes lose track of time? * YES NO Have you ever found yourself daydreaming to the point that you don't pay attention to sounds around you? * YES NO When watching a movie, do you sometimes feel emotional during sad parts? * YES NO When you think of something funny, do you automatically smile or laugh to yourself? * YES NO Do you have a vivid imagination? For instance, can you imagine where you would go or what you might do on a vacation? * YES NO Do you find it easy to tell family of friends if something is upsetting you, or makes you happy? * YES NO Is there anyone who has earned your trust? * YES NO Do You experience any of these Habits? Check all that apply: Cutting Eating Issues (Over or Under eating) Hair Pulling Nail Biting Teeth Grinding None Other If "Other", Please describe: If you are human, leave this field blank.