Pre-Session Getting to Know You Form Please fill in this Pre-Session form at least two days before your appointment. The more information you give me in the large boxes, the better. It allows me to get to know you better and it also saves us time for the work that needs to be done. I want to make every minute count. Name: Phone: Alt. Phone: E-Mail: Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR PW VI Zip Code: Country: United States Mexico Status: Single Living together Married Divorced Have you ever been hypnotized before? Yes No What is the current negative situation that you would like to change? Are you currently seeing a physician for these issues? No Yes If yes, please give the Physician's name and City/State Would you like me to keep him/her updated on your progress? Yes No How does this situation affect you physically and emotionally? What would it be like if I helped you rid yourself of this situation? What would that be like for you? Now for a few miscellaneous questions: What is your favorite color? Think of a special place that you love to go to where you feel everything is absolutely perfect - just the way you like it. Where is it? What is it about that place that you love so much? Have you ever walked in your sleep during your life? Yes No Have you ever awakened in the middle of the night and felt that you could not move your body and/or talk? Yes No As a teenager, did you feel comfortable or uncomfortable expressing your feelings to one or both your parents? Uncomfortable Comfortable As a child, did you feel that you were more affected by your parents tone of voice, than by what they actually said? Yes No Do you feel that you learn and comprehend better by: (Check all that apply) Seeing Reading Listening Do you find it easy to be at ease and comfortable with your movements, even when faced with unfamiliar people and circumstances? Yes No Is there anything else that you would like to add? PRIVACY POLICY