Our First Session
The following questions not only help us understand how to help you but also prepare your mind for our discussion.  This information will be held in confidence between you and your hypnotist.  Please complete this the day before your scheduled appointment.  

Valerie Grimes, CHt
5310 Harvest Hill Rd. Suite 135
Dallas TX 75230
972-974-2094

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Email *
Your name *
Address: Street, City, State, Zip *
Preferred phone *
Please list an emergency contact with phone number *
Date of birth
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Please write a few paragraphs explaining your current situation and what you are wanting assistance with. *

How long has this been an issue?

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Why is it important to resolve this issue?

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Under what circumstances did you first experience this problem? 

How will your life look or feel when this issue is resolved? 

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What kind of internal/external resources do you have that help you cope with life and its issues and problems?

What/who makes life more difficult?

What other forms of therapy have you tried for this issue?

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What is your occupation? Do you enjoy your work? *

What do you do to relax? 

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What are your interests/hobbies?

Do you have any problems with the following?

Do you engage in any form of regular exercise? 

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What are you religious or spiritual beliefs? I will incorporate them into the session if so desired.  I honor all beliefs.

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Who supports your desired changes?

Is there anything that I haven’t asked that you feel is important for me to know?

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In the past or are you currently experiencing  any of the following? Check all that apply: *
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Do you have any health concerns?
Do you have any questions or concerns?
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