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Let go of your stress hypnosis
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Hypnosis for Fear of flying
Hypnosis to Improve Confidence
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Hypnosis FAQ
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Talk to Trisha! 360-885-1965
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Home
BWRT®
Services
Let go of your stress hypnosis
Quit Smoking Hypnosis
Hypnosis to lose weight
Hypnosis for Sleep Issues
Hypnosis for fears and phobias
Hypnosis for Fear of flying
Hypnosis to Improve Confidence
Forms
About
My Approach
Client Testimonials
Hypnosis FAQ
Free Download
Blog
Contact
Talk to Trisha! 360-885-1965
0 items
Hypnosis general information form - Focus With Hypnosis
22241
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Hypnosis general information form
Step
1
of
6
- Personal
0%
Date
*
MM slash DD slash YYYY
Personal
Name
*
First
Last
Phone number (preferred)
*
Alternate Phone
What time zone are you in?
*
Gender Identity
Email
*
Age
*
Date of Birth
*
MM slash DD slash YYYY
If referred, by whom?
Family
Relationship Status
*
Single
Married
Divorced
Widowed
Name of Spouse or Partner
*
Do you have Children?
*
Yes
No
Children
*
Name
Age
Gender Identity
Vocation/Education/Interests
Occupation
*
Brief Work History
*
Education
*
Military Service
*
Yes
No
Retired
Hobbies and Interests
*
Please briefly describe your spiritual or religious beliefs or life philosophy
Physical Health
Do you consider yourself in good physical health?
*
Yes
No
If no, please explain
*
Medical Conditions & History
*
Briefly List/Describe
Are you currently taking any prescription medication?
*
Yes
No
List Current Prescriptions
*
Name of prescription and what your taking them for:
Are you currently under a physician’s care?
*
Yes
No
If yes, please specify for what condition(s)
*
Do you smoke or use any other form of tobacco?
*
Yes
No
If yes, how much and how often?
*
How much per day/week/month:
Do you drink alcoholic beverages?
*
Yes
No
If yes, how much and how often?
*
How much per day/week/month:
Recreational Drug Use (if applicable)
Mental Health
Are you in good mental health?
*
Yes
No
Have you ever received treatment for a mental health condition?
*
Yes
No
If yes, please list any mental health condition(s) and treatment:
*
Have you ever taken prescription drugs for anxiety, depression, or any other mental health problems?
*
Yes
No
If yes, please list the prescription drugs
*
On a scale of 1 - 10, 10 being maximum how would you rate your stress?
*
Please enter a number from
1
to
10
.
Briefly describe the causes of stress:
*
*Note
If you are seeking hypnosis or BWRT® for a medical issue it may be necessary to obtain your physician’s approval to use hypnosis or BWRT® as an adjunct to medical treatment. Let’s discuss this before your first session.
General
Do you use relaxation techniques such as meditation or mindfulness?
*
Yes
No
Sometimes
Please describe technique and frequency
*
Have you had Hypnotherapy/Hypnosis or BWRT® previously?
*
Yes
No
If so, when? For what? Was it helpful?
*
Please give your reason(s) for seeking BWRT® or hypnotherapy/hypnosis
*
Any particular questions or concerns that you may have about BWRT® or hypnosis?
Choose all that apply
*
Vocation Related
Business Related
Health Related
Stress Reduction
Living a Happy Life
Positive Thinking
Achieving Goals
Relationship Problems
Improve Self-Esteem
Success Motivation
Choose all that apply
*
Sports Performance
School & Education
Study Habits
Test Anxiety
Procrastination
Perseverance
Memory/Recall
Pre/Post Surgery
Pain Management
Sleep Issues
Choose all that apply
*
Weight loss
Stop Smoking
Substance Abuse
Alleviation of Fears
Nervousness
Situational Stress
Self-Control
Resolving Past
Grief/Loss
Past Life Regression
Is there any additional information that you feel might be helpful for me to know?
Email
This field is for validation purposes and should be left unchanged.
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