Transformational Hypnosis

Initial Intake Goal Questionnaire

Please fill out the following questionnaire at your convenience and bring it with you to your intake session.

(ALL INFORMATION IS CONFIDENTIAL)

First name

Last name

1. What do you need to improve?

2. List difficulties that you have been experiencing:

3. What methods have you tried to improve your difficulties?

4. What aspects of those methods worked? What did not work?

5. In your evaluation, where do you think the difficulties stem from?

6. Can you identify one (1) or two (2) beliefs that you consider to be self-sabotaging or self-critical (ex: things you say to yourself)?

7. List three (3) of your best reasons to improve your difficulties

8. List three (3) things you look forward to upon achieving your goals:

9. Have you ever been hypnotized Y or N (if so, describe when, where, why, and by whom.)

10. Name something that feels good:

11. Name your three (3) favorite places:

12. Name your three (3) favorite colors:

13. List any hobbies:

14. Name someone you admire and why:

15. Why is it time to resolve this difficulty now?

Additional comments and/or suggestions:

Name:

Phone:

Email:

Signature

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