Intake Form for 3 Hypnosis sessions

Before you book a session, please, fill out the information below
Part 1: Your contact information

*required fields
Name*
Email*
WhatsApp phone number
 
Part 2: Your personal information

*required fields
Age*
Preferred pronouns?
 
Part 3: Your health information
Health problems
current and past
Medication being taken
From the list below mark the areas that concern you
Other area of concern, not listed above
please specify
 
Part 4: Your expectations

*required fields
What would you like to work on during this session?*
Describe briefly what would your life look like without the problem?
What are you most proud of in your life?
Any other information you feel may be important for the session
Have you been hypnotized before?
How did you find me?*

Next you will be redirected to the payment page to finish