Hypnosis & Hypnotherapy in West End, Vancouver BC

Application and Personal Data Record – Client Assessment Form

Before we have a session, please  fill out the form below. It helps me understand your challenges and issues that we will work together on. Filling out this form online will save us some time of your first session. Your personal information is completely confidential. All responses are secure and will only be seen by your hypnotherapist Kemila Zsange. Thank you!

Or if you don’t like to do it online, you could also download the PDF file Application-Personal-Data-Record, fill it out, and bring it to our first meeting.

Your Name (required):

Your Email (required):

Gender:

Date of Birth(d/m/y):

Address (required):

City/Province/Postal Code (required):

Day Telephone:

Evening Telephone:

I prefer to be contacted by:  Day Evening Either

Occupation:

Martial Status:

Person to call in An Emergency? (required):

Emergency Person's Phone Number (required):

Have you ever been hypnotized before?

If yes, by whom?

If you were to close your eyes, could you visualize an image or scene if it was described to you?

Presenting Issue:

When and under what circumstances did this issue begin?

How has this affected your life?

Has it ever been different?

What specifically about your issue is leading you to seek help?

Do you associate any of these emotions with your issue?

Abandonment Anger Anxiety  Boredom Depression Embarrassment Fear Frustration Grief Happiness Loneliness Loss Relaxation Sadness Shame 

Others

Are you currently on any medication?

What is your 1 month goal regarding this issue(s)?

What is your 6 month goal regarding this issue(s)?

What is your 1 year goal regarding this issue(s)?

What is your 5 year goal regarding this issue(s)?

What are your availabilities for the initial appointment? Please put some hours and dates that work for you here so that I can select one and block the time for you.

If there is anything else you think it's helpful for me to know, say it here, or upload a file here:

Thank you for the first step you’ve just taken towards your well-being! A confirmation for the first appointment will be sent to you once it’s reviewed.

To further save your time during our first session, you may want to do Suggestibility Quiestionnaire online now. It is to tell if you are more left brain or right brain dominant.

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