We ask that all clients provide a full and complete confidential history so that we may best assist you.  Some medical-related questions are pertinent and important as we do not want to interfere with any ongoing treatment or care. If you have questions regarding this form please contact me at  Thank you.

Contact Information


Client Information

Have you ever received professional hypnosis or coaching before?

If yes, what was the reason and how did it go for you?

Has anyone ever tried to hypnotize you?

If yes, do you believe you were hypnotized and why?

When appropriate we find it useful to use a holistic approach (mind-body-spirit). Would you consider yourself a spiritual person?

What is your main purpose for purchasing this program? What issue are you most looking to resolve/eliminate at this time? *  

Have you attempted to address this issue before?  What did or didn’t work?

Medical History

Are you currently undergoing medical or psychological treatment for the ABOVE issue/concern?
Have you been under a doctor’s care in the past year?

If you answered "yes" to either of the questions above, please explain your reason for care.

Have you ever been treated for mental/emotional health related concerns?
Are you currently receiving treatment or counseling for mental/emotional health related concerns?
Have you every been treated for:
Have you been diagnosed with a chronic health condition or been treated for a prolonged illness?

If yes, please explain.

Are you currently taking perscribed medications?

If yes, what are you taking and what is the purpose of this medication?

Are you currently taking any mood or mind altering supplements/subtances that effect your level of focus/concentration?

If yes, what are you taking and why?

Emergency Contact Name, Info & Relationship *

Do you have any questions about hypnosis or coaching?

All appointment changes or cancelations require 48 hours of advanced notice prior to your scheduled appointment.