Magically Spiritual Hypnotherapy Application

HYPNOTHERAPY INTAKE FORM

NOTE: After filling out the form, you will receive an e-mail in 24 to 48 hours. Thank you for your patience.

Date of Birth

Location of Birth

Time of Birth (If you don't know it, leave blank.)

Have you experienced hypnosis or hypnotherapy? Describe.

Have you ever been diagnosed with any medical or mental health condition? If so, please list the diagnosis/diagnoses.

For remote sessions, you must have a headset with an in-built microphone, a cam and wifi that's stable for 90+ minutes is required. Do you have these things?

What issues do you want to focus on now? What issue is your priority?

What old habits, thoughts, or emotions would you like to change?

What new habits, thoughts, or emotions would you like to replace them with?

What success have you had in the past with these or related issues?

List any additional comments you want to say below:

If you have a discount code, list it below: