Intake Form

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Client Information Form

* Indicates required field

Gender *

Date of Birth *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Type of Phone *

Alternate Phone Number *

Type of Phone *

Your Email Address: *

Additional Comments Regarding Contacting You: *

Occupation *

Voucher Number or Coupon Code (if applicable): *

Please describe the reason for your coaching appointment: *

What methods have you attempted in the past to resolve your issue(s)? *

What might be some of the possible reasons these issues haven't been successfully resolved in the past? *

Describe your PRIMARY goals for your coaching experience: *

Describe your SECONDARY goals for your coaching experience: *

Are you comfortable utilizing hypnosis as one of the tools to assist you in reaching your goals? *

Yes No

Describe your thoughts of hypnosis & any prior familiarity or experience you've had with it. *

Are you currently under the treatment of a medical or psychological professional regarding this or any relevant issue? *

Yes No

If so, please describe the nature and status of the treatment and provide his or her contact information. *

Please share anything else you'd like your coach to know: *

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"We are, what we repeatedly do. Excellence, then, is not an act, but a habit."
William Durant