Hypnosis Recording Intake
Required Field
___________
A payment link will be sent to the email address provided. Recording of your purchase will not start until payment has been recieved.
___________
Personal Info
First Name
Last Name
Pronouns
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
Gender
Male
Female
Identify as
Identify as
Contact Info
Mobile Phone
Email
Source of Referral
General Information
Imagery is often used during a recording. Is there anything that I should AVOID?
Stairs
Escalator
Elevator
Heights
Floating
Water/Ocean
Other
Characters:
0
/255
None
Have you been diagnosed with any of the following?
Schizophrenia
Chronic Depression
Bi-Polar
Heart Disease
Epilepsy
None
Are there any other health issues your practitioner should be aware of?
Characters:
0
/255
Your personalized recording
What are you wanting to focus on in your recording?
Stress/Anxiety
Worry
Fear of the future
Insomnia due to overthinking
Please give me a brief description of your history with this issue, how the symptoms manifest for you and anything else you would like me to know.
Describe with as much detail your perfect, safe, relaxing place. Doesn't have to be a real place or somewhere you've been. The more information you provide, the more personalized tihs will be.
Sights
Characters:
0
/255
Smells
Characters:
0
/255
Sounds
Characters:
0
/255
Any specific textures or feels
Characters:
0
/255
Would you like your recording to wake you up at the end or talk you into sleep?
Wake me up
Talk me into sleep
Both (additional $15)
Is there anything else you would like me to know?
What would be the best way to contact you if I have any additional questions? Please provice phone number or email address.
Characters:
0
/255
Review & Agree
Hypnosis Recording
(Review Required)
You need to review and accept this before submitting
Signature
×
Submit Form
×