Basic Info — Shift Hypnosis

Basic Information & Benefits Form

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

Occupation

Number of Children

How did you hear about me?

Reason for Hypnosis

What is the reason you're coming in for hypnosis? (the change you want to make)?

Healing Journey

What have you tried already to fix this issue?

Hypnosis Experience

Have you ever been hypnotized before or seen stage hypnosis? Generally, what was the experience?

Success

What would be an indicator of "success" with this goal for you?

Four Positive Benefits

Please list four additional positive ways your life will be affected by this change.

Spirituality

Would you consider yourself a spiritual person? Briefly describe, please.

Questions or Concerns

Do you have any questions or apprehensions? Briefly describe please.