New Client Interest Questionnaire
Healthy Heart Hypnosis - Jodi Hert Hypnotherapist
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Your name:
Best email address to contact you:
What would you like to work on using hypnosis? If multiple topics, please list in order of importance to you. (Please note: There are a few topics that I am not currently working with clients on, such as smoking cessation, but I will let you know if your topic is one of them. For Past Life/Life-Between-Lives Regression sessions I do have a waiting list so please be sure to fill out the correct form to be added to the waitlist.)
Is the hypnosis session for you or someone else (minor)? If someone else, what is their age? (If for someone else, please fill out the questionnaire from their perspective.)
Have you ever been seen by a medical doctor or other type of therapist for this same topic? If yes, was there a diagnosis given and/or any treatment plan?
Have you ever done hypnosis before? (Check all that apply)
What types of things have you done previously to try to work on the topic that you are wanting to use hypnosis for? What kinds of results did you have?
On a scale of 1-10, how much does this topic impact your day-to-day life?
Does not impact
Greatly impacts
Clear selection
On a scale of 1-5, how greatly do you want to see this topic resolved in your life?
It would be nice
It WILL be resolved
Clear selection
Do you have any strong religious or spiritual beliefs you’d like me to be aware of? If yes, we will discuss once we start working together. I will be sure to be very respectful of your beliefs.
Clear selection
How did you find me?
I look forward to touching base with you soon!   Jodi
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