Emergency Contact (Name & Phone):*
What is your biggest current challenge, problem, or area of struggle? (Please describe in detail.)*
What would you like to see shift or change regarding this challenge? (Please describe how you'd like things to be different.)*
What would life look like for you if this shift were to happen or your goal was achieved? (Be as specific as possible about what would change in your life if this challenge was resolved.)*
If you were to achieve this goal or shift, what would be different in your daily life, thoughts, or emotions? (Consider practical, emotional, or psychological changes.)*
Why do you think this challenge or issue has persisted in your life? (What factors, patterns, or beliefs do you feel have contributed to this ongoing issue?)*
What thoughts and feelings come up for you when you think about this challenge? (Please describe any emotions, anxieties, or limiting beliefs you associate with it.)*
How long have you been experiencing this challenge or pattern? (Please estimate the duration of the issue, whether it’s something recent or ongoing.)*
What have you tried in the past to resolve or manage this issue? (Please include any strategies, therapies, or actions you've taken.)*
Please list any medications you are currently taking.*
Are there any other personal or emotional issues you'd like to address through hypnotherapy? (This could include stress, anxiety, limiting beliefs, confidence issues, etc.)*
What do you hope to achieve or experience from these hypnotherapy sessions? (Be specific about your expectations and goals.)*
Is there anything else you'd like to share to help us understand your situation better? (This could include medical history, past trauma, or any other relevant information.)*
Consent for Hypnotherapy:*
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