First and last name*

Are you over the age of 18?*

Mobile number

Email address

List any prescribed medications you are taking *

How did you hear about my services?*

Name and phone number of emergency contact*

gender identity?*

Have you ever been hypnotized before? If yes from whom?*

Are you being treated for any mental health conditions? If yes, please explain*

Are you currently, or have you ever been under the care of a mental health therapist or counselor?*

What is your presenting issue?*

What specific goals do you hope to achieve through hypnotherapy?*

How do you think hypnotherapy can help you?*

Is there anything else you would like me to know?*