Guided Hypnosis Intake Form Client Intake FormΔ Newsletter Step 1Step 2Step 3Step 4Step 5Step 6Personal InformationLet's start with the basics. I collect this information to stay in touch and ensure I have everything needed to support you safely. Rest assured, your information is encrypted, stored securely, and remains 100% confidential. I value your trust and protect your personal details with the highest standards of privacy.FirstLastAddressAddress Line 1Address Line 2CityCounty / StatePostcode / Zip CodeCountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhone Number (Mobile preferred)EmailNicknameI Prefer to be Updated by: Email SMS WhatsappYour Birth Gender--- Select Choice ---MaleFemalePreferred Gender & PronounsDay of Birth- Select -1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31stMonth of Birth- Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear of Birth- Select -20102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946Age Confirmation I confirm I am at least 16 years oldService Booked Guided Hypnosis Coaching Spiritual HypnosisSave & ResumePreviousNextYour Intention & GoalsNote that I can provide closed-content sessions where you do not need to share any details about your needs, history or experiences. If you wish not to share these details, please just enter 'PRIVATE' in the fields below.Reason for Seeking TherapyGoals for TherapyWhy have you come for therapy now?Do you have any experience with hypnosis or hypnotherapy?Do you have any concerns or questions about guided hypnosis?Your Intention & GoalsNote that I can provide closed-content sessions where you do not need to share any details about your needs, history or experiences. If you wish not to share these details, please just enter 'PRIVATE' in the fields below.Reason for Seeking Spiritual HypnosisGoals for Our Session(s)Do you have any experience with spiritual practices or learnings?Do you have any experience with hypnosis or hypnotherapy?Do you have any concerns or questions about spiritual hypnosis?Save & ResumePreviousNextYour Goals and MotivationsThis section is designed to help me understand exactly what you wish to achieve. By sharing your current challenges and goals now, I can tailor our session to your specific needs. Please don't feel pressure to get this 'perfect.' If you are unsure, a rough idea is better than nothing. We will refine it together once we get started.What are your short-term goals? Where would you like to be in 12 months?What are your long-term goals? Where would you like to be in 5 years?How frequently do you feel you need to review your progress to stay on track? Daily Weekly Monthly Quarterly Every 6 Months I don't review my progressDo you have any experience with being coached? What are your expectations of our coaching journey together?How can I best support you throughout this relationship?PreviousNextMedical & Mental Health DetailsWhile there are certain ethical and legal boundaries regarding who I can work with, I always aim to find a safe way forward whenever possible. By sharing your medical or mental health history here, you allow me to accurately assess how I can best support you—or if we need to adapt our approach to ensure your well-being.Have you ever been diagnosed with a mental health condition (including personality disorders)? Yes NoAre you currently receiving treatment from a psychiatrist, psychologist, or mental health professional? Yes NoDo you have current or recent suicidal thoughts, or urges to harm yourself? Yes NoDo you have any other medical conditions (or suspected conditions) I should be aware of? Yes NoIf you have answered 'Yes' to any of the question above. Please share additional details here.Details from your GP or SpecialistPlease indicate if you are currently taking medications related to any of the following: Mood & Depression (e.g., SSRIs, SNRIs, Antidepressants) Anxiety & Sleep (e.g., Benzodiazepines, Sleeping aids) Psychosis or Bipolar Disorder (e.g., Lithium, Antipsychotics) Neurological / Seizures (e.g., Anti-convulsants, Epilepsy medication) NONE OF THE ABOVE OtherPlease detail any previous therapy experiencesPlease share any details of any family mental health issuesHave you been hospitalised for psychiatric reasons in the last 12 months? Yes NoDo you have a history of psychosis, hallucinations, or hearing voices? Yes NoHave you been diagnosed with a dissociative disorder (such as DID)? Yes NoDo you have epilepsy or a seizure disorder? Yes NoDo you have any neurological conditions (e.g., brain injury, stroke)? Yes NoAre you currently pregnant? Yes NoIf you have answered 'Yes' to any of the question above. Please share additional details here.Emergency ContactAre you able to have somebody be in the same home as you during our session in case of emergency? Yes NoSave & ResumePreviousNextYour Life-Balance"I’ve designed this section to be quick and straightforward. Just a few brief details to give me a snapshot of where we are starting. Don't overthink it—it's really designed to start a conversation about your priorities. On a scale of 1 to 10, how satisfied are you currently with these areas of your life? (1 = Very Dissatisfied, 10 = Fully Satisfied).My Employment & Career0Finances0Friendships & Social Life0Fun & Recreation0Health & Vitality0Personal Growth0Romance / Significant Other0Your Home Environment0Save & ResumePreviousNextYour CommitmentsTo ensure we get the best possible results, I ask for a few simple commitments from you. These agreements regarding attendance and engagement create a professional container for our work, allowing us to focus entirely on your progress once the session begins. Partnership Agreement Cancellations: I agree to provide at least 24 hours' notice to cancel or reschedule, otherwise the session is forfeited. Punctuality: I respect our start time. If I haven't arrived within 15 minutes, the session is a 'no-show' and will not be refunded. Late Arrival: If I arrive late, the session will end at the scheduled time to respect the next client. Scheduling: I take full responsibility for booking my own sessions and tracking my remaining credits. The Work: I understand real change happens between sessions. I commit to doing the suggested reflections and exercises. Debriefs: (Hypnosis) I acknowledge that booking a 'Debrief' after hypnosis is optional but highly recommended. AI Summaries: I acknowledge session summaries are AI-generated, may contain minor inaccuracies, and are for personal review only. Action Taking: I am ready to move from 'thinking' to 'doing.' I commit to taking action on insights rather than just analyzing them. Sobriety: I agree to attend all sessions free from the influence of alcohol or recreational drugs. Tech Check: I am responsible for ensuring my internet, camera, and microphone are working before the session begins. I have read and agree to above commitments Coaching Agreement Coaching is not Therapy: I understand that coaching is distinct from psychotherapy. While therapy often focuses on treating psychological issues or healing the past, our work focuses on clarifying my goals and creating strategies for the future. Coaching is not Mentoring: I understand that pure coaching focuses on finding my own answers, whereas mentoring involves you sharing how you achieved something. I acknowledge that while you are happy to share your experiences if I request them, the primary spirit of our work is my own discovery. Coaching is not Consulting: I understand that you will not simply tell me "how to do it." I acknowledge that I am far more likely to commit to a plan I have formulated myself, so I agree to do the thinking required to create my own solutions rather than expecting a list of instructions. Confidentiality & Safety: I understand that our sessions are strictly confidential. I trust that my personal details will not be shared with anyone, unless required by law or if there is a perceived risk of harm to myself or others. Ownership of Results: I acknowledge that while you facilitate the process, I am fully responsible for my own well-being and the results I achieve. I understand that coaching is a partnership, not a medical treatment, and ultimate success depends on my own choices. Honesty & Openness: I commit to bringing my full truth to the sessions. I understand that the coaching process relies on my willingness to be vulnerable and honest about what is really going on for me. I have read and agree to above coaching commitmentsSign HereYour Signature Previous Submit