CONFIDENTIAL QUESTIONNAIRE
Your success is our #1 priority. Help us to help you attain that success by filling out this questionnaire as completely as possible. This is a Three-page form. Thank You!
Name_________________________________________________ Date______________________________________
Address City State Zip
Home ph# Cell Ph# Email: __________________________________________
Age_______ Sex_______ Height_______ Weight_______ Favorite Hobby
Are you currently under the care of a physician? yes or no __________________
Did your doctor recommend that you use alternative methods? yes or no __________________
Physician’s Name __________________
Have you ever been diagnosed with epilepsy or had seizers? yes or no __________________
Do you exercise? _____ How often? _______________ What type? __________________
What worries you most? __________________
What do you want/expect from your private session? __________________
Have you ever meditated or been hypnotized before? _____Results ________________
Where did you hear about us? ________________
Why did you choose TRANSFORMATIONS? __________________
What is the longest period of time you have been free of it? ____________ __________________
How many times have you failed at getting relief? __________________
What methods failed to help you get relief? __________________
PLEASE GO TO THE OTHER SIDE TO FILL OUT THE REST OF THIS FORM ÞÞÞÞÞÞÞÞÞÞÞÞÞ
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Does your issue make you physically uncomfortable? yes or no
Did you know that Guided Imagery, NLP & EFT are 100% safe?
Are you embarrassed by your challenge? yes or no
Does your issue limit you and your activities in any way? yes or no
Does it affect you more under stress? yes or no
Do you feel your challenge controls you? yes or no
Are you affected because of emotions? yes or no
Is being free a top priority? yes or no
What do you think is the most difficult part about resolving your issue?
Do you believe relief has to be painful? yes or no
Briefly describe your behavior ______
Do you believe relief can be fun and enjoyable?
When do you want to be free?
Does your family support your efforts?
Does your challenge limit your social life?
Do you feel tired, run down and out of energy?
Can you remember being free of this challenge?
What do you remember about being free?
Has this issue caused you pain or suffering? (Describe physical and emotional pain)
Pick out of the four responses below what is the most important element in deciding to use
our services? (Circle one please)
** Effectiveness (your results)
** Time (how fast you get results)
** Service (how we respond to your needs)
** Affordable (what we charge)
I understand that my entire TRANSFORMATIONS client file will remain completely confidential unless permission is granted in writing.
A Hypnotherapist/NLP/EFT Practitioner makes no medical claims and is not a psychotherapist or a medical doctor, and is not responsible for any medical condition that the undersigned has now, had in the past or contracts in the future.
Payment in full is due at the time service is rendered unless agreed otherwise.
All Cancellations must be made 24 hours prior to appointment. Same day cancellations will be charged $65.00
The fee of $65.00 for your initial interview will be refunded upon completion of your customized program.
I agree to all the conditions above.
Signature Date
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I want to clear up the issue of…...
If there was an emotional cause behind the issue, I would guess it to be…..
List every bothersome event you can think of that increases your stress when you think about it:
What is the upside of you overcoming this issue?
What is the downside of you overcoming this issue?
List everything you want out of life….and then prioritize your list.(you may do so on opposite side of page)