General Consult Questionnaire How did you hear about us? (please check ALL that apply)
Are you currently under the care of a physician?
Did your doctor recommend that you use hypnosis?
Have you ever been diagnosed with epilepsy or had seizures of any kind?
Did you know that hypnosis is 100% safe?
Have you ever been hypnotized before?
Does your problem make you physically uncomfortable?
Are you embarrassed by your habit/behavior?
Does your behavior problem limit you or your activities?
Does it affect you more under stress?
Do you feel your problem controls you?
Are you affected because of emotions?
Is being free of your behavior problem a top priority?
Do you believe that ending your behavior has to be painful?
Are you willing to believe that changing your behavior can be fun and enjoyable?
Does your family support your efforts?
Is your family excited about you using hypnosis?
Does your problem limit your social life?
Do you feel tired, run down and out of energy?
Can you remember what it was like before the problem?
Has your problem caused you pain or suffering? (physical and emotional pain)
What is the most important element in deciding to use our services?
SUBMIT
