Soul Glow WellBeing, Weight Loss with Hypnotherapy

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Soul Glow WellBeing, Weight Loss with Hypnotherapy - Intake Form

Holistic Healing Support Provided by Becca Briley, Ordained SoulWorker, Master Life Coach & Hypnotherapist

Email *

Blessings on your journey to empowered wellbeing by making the choice to lose the extra weight once and for all! I welcome you to work with me 1:1 by filling out this form in all honesty. This is confidential and a non-judgmental support.

Full Name *

Brithdate *

YYYY

How old were you when you felt weight became an issue? (Be as specific as possible) *

How often do you exercise or get healthy movement? *

How would you describe your diet? Be as specific as possible?

How would you describe your relationship with food? Any eating disorder history in your life, or in your family history? *

Why do you want to lose weight, and for whom are you doing so? *

Do you WANT to lose weight and keep it off? *

Can you see yourself as being healthy, fit and active? *

100% - I see it clearly

Kind of - others are telling me I need this

I don't really want this support, but have no other option because of health issues

Yes, but I think I might have some self-sabotaging tendencies

Other:

How will your life be different when you are at your ideal weight? *

What is your biggest fear about losing weight? *

Do you have any unrelated fears that you need to inform me of? Ex: Fear of elevators (This will help me to formulate mindful scripts for your success) *

Do you prefer the beach, mountains or forest? *

Beach

Mountains

Forest

Other:

What is your favorite food and why? (Please offer a healthy favorite and non-healthy favorite) *

What are some of your habits related to your mealtime and eating preferances? (Be as specific as possible) *

Do you have children, if so how do you feel about their diet?

Do you have a dietary system that you adhere to? (EX: Keto, Vegetarian, Vegan) If so, please explain *

Do you live with others who eat in unhealthy patterns that you are aware of? *

Yes

Has anyone close to you lost a good amount of weight? What happened? *

What do you intend to gain from us working together? Please set an Intention. (You are planting a seed for manifestation here) *

Do you understand that this will be self-funded, holistic support? *

Yes

What is the service package agreement that you choose moving forward? (This will be based on your seriousness to quit and how quickly change shows) *

$175 Per Session (Pay each session)

3 Month Support Package ($125 Per Session Once a Week)

6 Month Support Package ($150 Per Session Bi-weekly)

12 Month Support Package ($145 Per Session Bi-weekly)

Other:

Do you prefer in person or virtual sessions? *

Virtual

In Person

Other:

Required

Please make payment prior to each session. *

I understand

I need to setup a payment plan

I'd like to pay in full, up-front to invest fully in my health

Other:

Required

If you are working with a primary care physician or mental healthcare specialist who you need to consult with before working with Becca, have you done so? *

Yes

Do you agree to receiving confidential, self-healing support provided by Becca Briley, Ordained SoulWorker, Life Coach, Nutrition Specialist, Reiki Practitioner, Mindfulness Mentor & Hypnotherapy Practitioner? (Becca is not a licensed therapist, counselor, psychologist or psychiatrist.) *

Yes

Send me a copy of my responses.

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