Exist In Excellence

ExistInExcellence@gmail.com
phone 262-373-9478

ALL INFORMATION IS STRICTLY CONFIDENTIAL

Name: __________________________________ Email: ______________________________

Phone: Home #___________________________ Cell #_______________________________
Address: _______________________________________________
City: ___________________________________ State:__________ Zip code: ______________
Occupation: __________________________________
Date of Birth: ____________________ Sex: ______________ Married: _____ Single:_____
Health Problems (Physical/Emotional/Psychiatric):_____________________________________
Are you under a doctor’s care? Yes _____ No _____
Reason for seeking Hypnotherapy: _______________________________________________
Previous efforts for resolving this problem?__________________________________________
If yes, with whom?_____________________________________________________________
Have you ever had: Diabetes?: ___________ Epilepsy?: __________ Heart Condition?:______
Cancer?: ______________ Digestive Problems?: _________ Other?: ___________________
Do you sleep soundly?: ______________________ Do you ever sleepwalk?______________
Do you have any fears (water, heights, etc)?: ________________________________________
Have you ever been hypnotized before? Yes ______________________ No ____________
When?: ________________________________ By Whom?____________________________
What do you expect from a Hypnosis session?________________________________________
Do you have any questions about Hypnosis?_________________________________________
______________________________________________________________________________

I, the undersigned, understand that Hypnotherapy is a conditioning process

whereby an individual is taught to USE THEIR OWN ABILITIES for their
own BENEFIT.
I further understand that ALL HYPNOSIS IS SELF-HYPNOSIS. The
Hypnotherapist is a coach or trainer who assists me to learn how to more
fully use the innate talents and capabilities I already possess. At no time
will I relinquish my free will, and will participate only at a pace and level
of involvement which is desirable and beneficial to me.

Signed: __________________________________ Date: _____________

Name I like to be called: ________________________________________