Equestrian Hypnotherapy Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Your answers will be kept strictly confidential and deleted once your recording is finalised.

Please fill out the following form, giving the first thought that comes to mind for each question that applies to you. The more information you supply, the better I can tailor your hypnotherapy to meet your needs.

Your Name *

Horse's Name

Date *

YYYY

Occupation

Mobile Number *

Landline Number

Names of anyone else involved with your issues / your horse *

Have you ever had hypnotherapy before *

Yes, for this issue

Yes, for a different issue

What are your 3 favourite colours? *

What are your 3 favourite places? *

Would you prefer me to use words like relaxation and sleep, rather than ‘trance’ or do you have no preference? *

Prefer 'sleep' and 'relaxation'

No preference

How do you know your issue is a problem? *

What obstacles do you face because of this problem? *

List up to 3 of your hobbies or pastimes *

If you could wish to be, do or have something, what would it be? *

All of my life, I …………. *

I am a person who…………………. *

What behaviours get in the way of your happiness on your horse? *

What would you like to start doing? *

What would you like to stop doing? *

What would you like to do more of? What would you like to do less of? *

What are the things you feel you should, can, and must do? *

What motivates you? *

Please list any specific needs or concerns or anything else that you would like included in your hypnotherapy. *

Is there anything you would rather not have included in the hypnotherapy recording, please click on those things you would NOT want included *

Heights

Tall buildings

Stairs / Staircase

Escalators

Open spaces

Closed spaces

None

Other:

How would you like to end the hypnotherapy? – E.g. will you be listening in the daytime and want to be wide awake, or listening just before you go to bed, in which case, you’ll want to drift off to sleep. *

During the daytime

In the evening

Just before bed

RELEASE STATEMENT I hereby authorise The Everyday Equestrian to produce for me a hypnotherapy session for the purposes outlined in this intake form and for the future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability and desire to effect change in myself. I understand that the results of my sessions depend greatly on my own serious participation, and that The Everyday Equestrian cannot offer any guarantee of the success Please print your name below. *

I agree

I disagree

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of theeverydayequestrian.co.uk. Report Abuse

Forms