JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Initial Client Questionnaire
This questionnaire helps me to prepare for our hypnosis session together, but you don’t need to answer anything you’re not comfortable with.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name (write pronunciation in brackets if you think needed)
*
Your answer
Telephone number
Your answer
Date of birth
MM
/
DD
/
YYYY
Tell me a little about your immediate family.
Your answer
What do you want from our sessions, the change you want?
Your answer
Why do you want this?
Your answer
Is there any reason that this change could be detrimental to you in any way?
Your answer
Do you ever possess or have possessed the change you want?
Yes
No
Clear selection
Have you had hypnotherapy before?
Yes
No
Clear selection
Have you taken part or been affected in any way by stage hypnosis?
Yes
No
Clear selection
To what degree do heights bother you?
Your answer
To what degree does water bother you?
Your answer
Was your childhood generally a happy/positive one?
Your answer
Anything else that bothers you that I should know about?
Your answer
Do you have a religious or spiritual belief? Please give basic detail.
Your answer
Can you think of someone now that you love dearly? You can think of more than one and this can include a pet even. If you do not have someone close, can you think of someone you really admire, this can be anyone, even someone that doesn’t know you.
Yes
No
Clear selection
Can you imagine what it would feel like to have the change you want? You may recognise how that would feel by yourself or you may want to imagine how that would feel based on how you perceive it from someone you know, even someone famous perhaps who has this quality you want.
Yes
No
Clear selection
Do you feel you have purpose in life? If so, what is your purpose?
Your answer
What can you be thankful for today? There will be something, no matter how small.
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
