Remember Me
Complete this form, press “Submit Information,” and it will be sent to me. Or if you prefer print it, fill it out, and bring it with you to our first meeting. (Fields in RED are required) First Name Last Name Street Address City State/Province Zip/Postal Code Country Abbreviation Birth Year Age Home Phone Emergency Services Phone (911 only if in Canada) Work Phone Cell Phone email Marital Status Names/Ages of Children
Trusted Contact Name Trusted Contact Relation Trusted Contact Phone
Main Interest
1. Do you have any fears or phobias? 2. Are you taking any medication? 3. Do you have any allergies? 4. Name two of your favorite colors. 5. Name two of your favorite places.
6. Are you currently diagnosed with a medical illness or condition and, if so, please list these diagnoses: 7. Other than those listed above have you been diagnosed with medical illness or condition in the past 3 years and, if so, please list these diagnoses: 8. If you are currently working with a doctor, healer, or health care practitioner for a current medical condition please list their names and specialties: 9. Have you previously been in psychotherapy or counseling and, if so, when and for how long? 10. Have you previously done any trance-based work or hypnotherapy and, if so, what? 11. What conditions are you interested in working to remediate, or what aspects would you like to enhance: 12. Do I have your permission to contact all of the health care providers that you have listed in order to discuss your treatment and condition? (If some, then specify.)
13. When startled or surprised, what do you do first: visualize the situation, listen to what’s going on, or focus on how you feel? 14. Which is more appealing or interesting: visual images, music, or human touch?
