Personalized Hypnosis Sessions with Kamelia

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All information will be kept strictly confidential. Please be aware that the more you can tell me about yourself, the more I may be of assistance to you. Feel free to go into detail about any issue you wish me to know about you, or to help you with.

Full Name *

Email *

Phone Number

Age *

Where are you located? City, State, Country *

Current Occupation *

Do you enjoy your work? *

Have you experienced hypnosis before? *

Do you have any current health problems? If so, please provide further details of conditions and treatment. *

List any medications you are currently taking & for what they are for. *

Please list any fears, phobias or compulsive tendencies. *

Please list any other conditions occurring in your life that you believe are negatively affecting you in any way, or provide details of your concerns, needs or fears. *

How would you like Hypnotherapy to help you? *

Sometimes we have a few problems to resolve. If you could narrow it down, which one is more important to work with in our Hypnotherapy session and why? *

Now, imagine yourself without this problem. How would your life be different? *

What (if anything) would you like to do better in your life? *

What is your greatest dream for yourself? *

I hereby authorize Kamelia Britton to use Hypnosis Techniques on me for the purposes outlined in this form, and for future purposes that I may request. I understand that Hypnosis and Regression Therapy are not medical procedures and that no medical benefits are being offered to me. I understand that the success of Hypnosis and Regression Therapy depends on my ability to relax, and my desire to create change in myself. I understand that because the results of the sessions depend on my own serious participation, Kamelia Britton cannot offer any guarantee of the success of my treatment. I am aware however, that she will do everything reasonable in her ability to ensure my success. *

I agree

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