Hypnotherapy Questionnaire
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Email *
Your answers will be kept strictly confidential and deleted once your recording is finalised
Please fill out the following form, giving the first thought that comes to mind for each question that applies to you. The more information you supply, the better I can tailor your hypnotherapy to meet your needs.
Name *
Male/female
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Occupation
Email *
Phone number
Names of anyone else involved with your issues and in what capacity
Briefly, for which issue(s) are you seeking hypnosis?
Are you currently suffering from any of the following (please tick all that apply)?
1. What are your 3 favourite colours?
2. What are your 3 favourite places? *
3. Have you ever had hypnotherapy before *
4. Would you prefer me to use words like relaxation and sleep, rather than ‘trance’ or do you have no preference? *
5. How do you know your issue is a problem? *
6. What obstacles do you face because of this problem?
7. List  up to 3 of your hobbies or pastimes *
8. If you could wish to be, do or have something, what would it be?
9. All of my life, I ………….
11. I am a person who………………….
12. when are you happiest? What behaviours get in the way of your happiness? *
13. What would you like to start doing? *
14. What would you like to stop doing?   *
15.  What would you like to do more of? What would you like to do less of? *
15. What are the things you feel you should, can, and must do?
16.  What motivates you? *
17.  What are your goals for this hypnosis? *
18. Please list any specific needs or concerns or anything else that you would like included in your hypnotherapy.
19. Is there anything you would rather not have included in the hypnotherapy recording, please click on those things you would NOT want included *
20. How would you like to end the hypnotherapy? – E.g. will you be listening in the daytime and want to be wide awake, or listening just before you go to bed, in which case, you’ll want to drift off to sleep. *
Please pay in advance of me preparing your hypnosis. Many thanks! Go to https://www.traceycolenlp.com/payment and select £90 for mp3  If you are booking a 1 hour session, it's £135.
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RELEASE STATEMENT I hereby authorise Tracey Cole to produce for me a hypnotherapy recording for the purposes outlined in this intake form and for the future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability and desire to effect change in myself. I understand that the results of my sessions depend greatly on my own serious participation, and that Tracey Cole cannot offer any guarantee of the success Please print your name below. *
Contact details
info@traceycolenlp.com
From the UK 07815016169
Outside of the UK ++ 44- 7815016169
Skype traceycolenlp

www.traceycolenlp.com
For more information on hypnosis for equestrians see https://www.traceycolenlp.com/equestrian-hypnotherapy/
A copy of your responses will be emailed to the address you provided.
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