Application for Hypnotherapy Services

Cooperative Healing for Mind, Body, Spirit.

* Indicates required field

Name *

First

Last

Email *

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you 18 or older *

yes no

Phone Number *

Can I text that number *

Yes No

Gender Identity *

Sexual Orientation *

Name/relationship/phone number for emergency contact *

How did you hear about my services? *

Are you being treated for Epilepsy? *

Yes No

Have you been hypnotized before? *

yes no

If yes, by whom *

List any prescribed medications you are taking. *

Are you currently, or have you been under the care of a mental health therapist or counselor? *

yes, currently yes, in the past no, never

Are you being treated for any mental health conditions? *

Yes, Currently yes, in the past no, never

If yes, please explain *

What is your presenting issue? *

How do you think hypnotherapy can help you? *

Is there anything else you would like me to know? *

I am interested in *

A single session Pre Paying for a package of 3 sessions Pre Paying for a package of 6 sessions Past Life Regression

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