In person and virtual services available.

Confidential Questionnaire

Your Success Is Our #1 Priority! Help us to help you attain your success by filling out this questionnaire as completely as possible. Thank you!

Confidential Questionnaire
Name
Name
First
Last
Address
Marital Status
How did you hear about us?
Are you currently under the care of a physician?
Did your doctor recommend that you use hypnosis?
Have you ever been diagnosed with epilepsy or had seizures of any kind?
Do you exercise?
Do you feel stress?
Did you know that hypnosis is 100% safe?
Have you ever been hypnotized before?
Does the problem make you physically uncomfortable?
Are you embarrassed by your habit/behavior?
Does your behavior problem limit you or your activities?
Does it affect you more under stress?
Are you affected because of emotions?
Is being free of your behavior problem a top priority?
Do you believe that ending your behavior has to be painful?
Are you willing to believe that changing your behavior can be fun and enjoyable?
Does your family support your efforts?
Is your family excited about your using hypnosis?
Does your problem limit your social life?
Do you feel tired, run down and out of energy?
Can you remember what it was like before the problem?
Has your problem caused you pain or suffering (physical and emotional)?
What is the most important element in deciding to use our services?