Hypnotherapy Interest Form for Inner Coach Counseling, LLC
Thank you for your inquiry about our hypnotherapy services. 

To help us better serve you, please complete the information below. This will help the hypnotherapist to better understand how to help you to achieve your goals.

Keep in mind that hypnotherapy sessions will be held via an online HIPAA compliant video conferencing platform. You can use your cell phone, tablet or computer as long as you have Wi-Fi.

Please answer the questions thoroughly and completely and we will get back with you as soon as possible!

Thank You,

Gena Golden, LCSW, NBCFCH
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HERE'S A LITTLE ABOUT ME 
My Training and Experience as a Hypnotherapist
Although I have worked with individuals, family's and groups as a clinical social worker since 1991, I began my training in hypnotherapy in 2013. Since then, I received hundreds of training hours in various hypnotic methods and have supported countless clients over the past 10 years on their hypnosis journey. 

My hypnotherapy work sits at the intersection of Neuroscience, Interpersonal Neurobiology, Mindfulness Meditative Practices, Positive Psychology, Anti-Oppression, Liberation-focused and Mind/Body Therapies. I am a National Board Certified Fellow in Clinical Hypnotherapy which mandates annual continuing education to maintain the highest professional development and practice standards. 

I am the owner and mental health practitioner to individuals, couples and families with a specialty in transgenerational, cultural and racialized trauma especially for communities that have been historically marginalized. Additionally, I provide a unique way of coaching called, 'Inner Coaching' to leaders, healers and change agents.
NOW, TELL ME ABOUT YOU
What is your First and Last Name? *
What are your Preferred Pronouns (she/her, he/his, they/them, etc) *
What is your preferred email address? *
What phone number can we reach you? *
What state do you currently reside? *
Have you ever been hypnotized? If so, please provide the reason, what your goals were, and the outcome.
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What led to your decision to do hypnotherapy? *
What else have you used or tried to address/correct/change your problem or to reach your goals? *
Was what you tried effective? *
MENTAL HEALTH
Do you have thoughts of hurting yourself or taking your own life?
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If Yes, please explain below *
Do you have thoughts of hurting someone else or taking their life?
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If Yes please explain below *
Have you ever been hospitalized for mental health concerns? *
If hospitalized, please indicate when and why. *
Are you receiving any mental health treatment now?
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What is the name of your mental health provider? *
Do you take any prescribed psychotropic medications? If yes, what are the names of the medications, and how do they affect you?
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MEDICAL/PHYSICAL HEALTH
When was your last visit with a physician?
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Was anything about this visit notable?
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Are you currently under a physician’s care for any of the above conditions?
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If so, name of physician and phone number: (if not, please indicate N/A)
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List any medical conditions or challenges: (if none, please indicate) *
Are you currently taking any prescription medications(s)?
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Have you spoken to your doctor, psychiatrist or therapist about utilizing hypnosis as an adjunct to your treatment? (Please explain)
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Some healthcare professionals would want to discuss your hypnotherapy treatment with them. Would you approve this and sign a release of information? (You have a right to refuse)
Clear selection
When under the care of a medical or healthcare professional it is best practice to informed your medical and mental health provider of your intention to use hypnosis as a method to reach your goals. Do you plan to inform them? *
SPIRITUALITY
Your spiritual practices matter and are valued. Please let me know how you would want your spiritual identity or practices incorporated into our work together. 
Please share what is essential to know about your spiritual/religious beliefs or life philosophy.
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CULTURAL 
Cultural identity is essential. It helps to shape who you are; your beliefs and cultural practices and values are shaped by your cultural practices. Are there things important to know about your culture's impact on your life or how you would like to incorporate cultural traditions in your work?
Share what is important about your culture, beliefs, values, traditions or customs. *
What else is essential to know about you? *
HYPNOTHERAPY GOALS
When someone has decided to seek hypnotherapy, it is because they have a problem they want to fix or a goal to achieve. Most people have tried other things but have yet to be successful. Some people want to get to the root cause of things. While others know they need support to shift unconscious beliefs to achieve their goal. Here is a list of reasons that many people seek hypnotherapy. You might find that what you are seeking is on the  list, but if it is not, it does not mean that we can not address it.

* To Cut Emotional Ties
* To Reduce Dental Fears
* To Forgive and Move On
* To Reduce Social Anxiety
* To Overcome Test Anxiety
* To Recover From Heartache
* To Decrease Fears and Phobias
* To Improve Sports Performance
* To Obtain Body and Weight Balance 
* To Increase Self Love & Body Positivity
* To Ease The Effects Of Labor and Childbirth
* To Improve Self Esteem and Confidence Building
* To Slay The Inner Critic, Imposter Syndrom and Self Doubt
* To Overcome the Fear of Public Speaking or Speaking Up For Self
* To Heal From Racial Trauma (includes historic and cultural trauma)
* To Heal Emotional Trauma (rejection, abandonment, abuse, neglect, bullying)
* To Heal Other Traumatic Experiences (crime victim, natural disasters, war, community violence, intimate partner violence)


What problem do you want to overcome, or what goal do you want to achieve? *
When your goal is met, what will you be able to do that you weren't able to do before? *
When your goal is met, who will notice?  What will they see about you that will be different? *
When your goal is met, how will your life be different? *
Video and Audio Resources
Check out the podcast on What Happens in Hypnotherapy

https://therapyforblackgirls.libsyn.com/session-45-what-happens-in-hypnotherapy
Brief  Description, History and Background of (5 mins ) Hypnotherapy
Scheduling
How soon would you like to be seen? *
Required
Fees
Hypnotherapy session can last between 60-90 minutes. 

We offer session bundles with discounted rates (if purchased in advance). 

They include: 3 sessions bundle ($450), 6 sessions bundle ($900) and 9 sessions bundle ($1,350). 

We accept debit and major credit cards as well as FSA (Flexible Spending Accounts) and HSA (Health Savings Accounts) through your employer. 

We do not accept commercial health insurance for hypnotherapy sessions or bundles.


Click Here If You Are Ready To Make Your Appointment
https://gena-golden.clientsecure.me
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