GENERAL CLIENT FORM
Please e-mail this form to . As soon as I receive it, I will send you a confirmation e-mail with the address.
The information you provide is strictly confidential. You get the same confidentially at Beach Hypnosis as you would get at your doctor’s office. It is really important that you answer all the questions with honesty. No need to be shy or embarrassed. I can help you better if I know all the facts upfront.
1.Today’s Date -
2.How did you hear about me?
3.Full Name -
4.What would you like me to call you?
5.Address –
6.Cell Phone -
7.E – Mail -
8.Birth date -
9.Male/Female -
10.Are you married or in a relationship and is it a happy one?
11.Profession/Title or Rank -
12.Education level -
13.What is your religious belief and do you believe in afterlife?
14.Do you prefer a tropical place or the mountains for a vacation?
15.Can you swim?
16.Do you have any fears or phobias (Dark, claustrophobia, crowded spaces, elevators, escalators, heights, flying, driving, crossing a bridge or tunnel, public speech, death, germs, snakes, spiders?)
17.Do you have any allergies (Cats, dogs, certain foods or drinks?)
18.Favorite color –
19.Do you smoke?
20.Do you drink alcohol?
21.Do you have any pets, what are their names?
22.Names and ages of children –
23.Are your parents alive and how close are (were) you to them?
24.Do you have any siblings and how close are you to them?
25.Did you have a happy childhood?
26.Name the people who ever hurt you and HOW -
27.Describe the current issue with details -What year did it start and did anything happen in your life when this problem start??
28.How is that problem affecting your life?
29.What situation triggers this unpleasant issue?
30.During the session I may touch your arm, hand, shoulder and forehead. Would that be ok with you?
31.Please list your preferred times and days for sessions :
32.By typing your name at the bottom of this page you accept the terms and conditions.
List additional issues that need attention. Please note that, there may be additional fees for any additional issues with a generous discount, unless otherwise discussed. Even if you don’t want to work on them just yet, it would be helpful for me to know, in order to fix the problem that you addressed primarily. However, I highly suggest that we fix all the problems at once since emotional issues, bad habits and addictions are always linked together and trigger each other. Not getting them fixed would be like putting gas in your car but not putting in any oil or changing an old tire that is also essential for a proper performance.
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Please continue reading the information below:
Hypnotherapy is very different than traditional talk therapy. Talk therapists are also known as "counselors" "therapists" and “psychologists.” They work with the conscious mind and the hypnotherapists work with the subconscious mind. They try fixing the problem on the surface; we go straight to the root of the problem that is buried deep in subconscious mind, which is a much more effective therapy.
Psychiatrists prescribe medications to their patients which most people don't like taking. They do not like being drugged up for the rest of their lives. Many parents report that drugs make their children violent and depressed. Also it can take years of therapy and countless visits with a traditional talk therapist before getting any positive results.
Hypnotherapy is NOT magic and hypnotherapists don't have a magic wand to fix all your problems with one visit. Even though hypnotherapy doesn’t take years to be effective like the other forms of talk therapy, depending on the number and the nature of the issues, it may take 3 to 20 sessions. Most children require at least 10 sessions.
Most emotional issues such as; depression, anxiety, panic attacks, fears, phobias, bulimia, weight gain, anorexia, nail biting, insomnia, and trichotillomania have root causes. You may need the following in order to improve the quality of life for yourself and start a new chapter in your life. An experienced and well trained hypnotherapist finds the root cause of the problem and helps you:
Regress to find the root cause of the problem
Deal with your inner conflicts using a “Parts Therapy” approach
Let go of anger, hate, emotional baggage, negative feelings
Forgive everyone who hurt you or did you injustice
Forgive yourself for any mistakes you may have done as a human being
Get over your fears and phobias
Remove blocks that has been preventing you from having a happy life
Increase your confidence, motivation and self-control
Erase bad memories
Replace bad memories with positive suggestions by reformatting your subconscious mind
Each of the issues above need separate sessions.