Hypnotherapy Intake

Basic Info

Name

First Name

Last Name

Today's Date

MM

DD

YYYY

History

Date of last hypnosis (if applicable).

MM

DD

YYYY

Has anything changed with your life/health since your last session with me? If so, please explain below:

What is your greatest hope for what we could accomplish through hypnotherapy in your appointment with me?

Please leave a brief description of your highest-priority issue, and what you're hoping hypnosis will help you achieve.

Have you read and do you agree with the terms in the disclaimer found at: https://khailoh.com/disclaimer

If you read the disclaimer referenced above, and agree that you are choosing into this experience with me, please type your name below indicating your signature.