Name *
Date of Birth *
Date of Birth
Address *
Phone *
Have you ever experienced Guided Imagery, Meditation, Yoga or Hypnosis? *
Do you enjoy your current work? *
Stress Level: Pain Level: Quality of Life:
Are you currently suffering from any of the following? *
I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnosis I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnosis with any doctor who is taking of me now or in the future. Additionally, I should continue any present medical treatment and consult my medical doctor for treatment for any new or old illnesses. Services are non-transferable. Sessions may be audio recorded for your protection, along with the hypnotist.