The NHC Client Intake Form
Hello there, 

Thank you for considering working with The Neo Hypnosis Clinic. 

We would really appreciate it if you filled out the form below so we can form an outline of your situation and determine whether we/hypnotherapy will be able to help you with your particular challenge. We don't want to waste your time and will do our best to point you to the right care if we deem that hypnosis is not a suitable treatment for your case. 

If we deem that hypnosis/hypnotherapy can help your particular case, we will reach out to you to book a FREE consultation session so that we can answer your questions, carry out a pre-session assessment, and fine tune our evaluation in order to write up your FREE treatment plan with our suggested beliefs. You can then decide whether you would like to proceed with a hypnosis session(s).

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Email *
Full Name (as in passport or official document) *
Which country and city/state/province/region are you based in?  *
What issue do you want to resolve?


If you simply want to experience hypnosis without a specific issue to resolve, we do provide beneficial beliefs that are applicable to any human being.

 *

How are you thinking, feeling or

behaving that causes a problem?

preferred answer structure

thinking: 

feeling: 

behaving: 
 *

How long have you had this problem?  

Do you remember when it first began?


 *
Are you currently seeing another mental health professional (psychiatrist, psychotherapist, psychologist, or counsellor)?

Your answer gives us a full picture of what professional support you currently or previously had. This will aid us in tailoring the treatment plan according to what has likely already been tried and estimating the amount of sessions that may be required to help you. 
 *
Required
Ideally, but realistically, after doing this work, how do you want to be thinking, feeling and behaving?

answer structure: 

thinking: 

feeling: 

behaving: 
 *
What are your motivations to change?
 *
What are the obstacles/triggers/doubts/challenges in your way?
 *
When or in what situations/contexts do you not have this problem? *
What else have you tried to overcome this problem and what happened?
 *
Thank you for filling out this form to the best of your ability. If you were unable to answer to your heart's content, we will have an opportunity to discuss anything you would like to delve into further during our consultation. Feel free to bring along questions regarding how I work, hypnosis, and hypnotherapy and I will do my best to answer. 

There will be no pressure to book a paid session in any shape or form. I only encourage you to make the best decision for your own growth and improvement. 

I will reach out soon, cheers! 
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