Hypnosis Recording Intake
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Personal Info
First Name
Last Name
Pronouns
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
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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
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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?
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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
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Smells
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Sounds
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Any specific textures or feels
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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.
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Hypnosis Recording
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