Homework Questionnaire

Name

Describe the place(s) that you feel the most safe and comfortable (real or imagined), where nothing could bother you:

Describe unpleasant places or fears that you have:

Describe 3 specific instances when you experienced an accomplishment you have been most proud of (lots of details please!):

Who will support you or sabotage your efforts to accomplish your objective and what might that look like?

Results (goal) I want:

Behaviors I need to change to see the results I want:

How I will know when I am successful:

My beliefs about this goal:

Expand 5 specific positive benefits to be gained from hypnosis & how they will change my life: reframe, add or subtract from my original benefit list on the questionnaire:

Hypnosis
&
Issues

Initial Consultation

Video Blog
& Photos

Schedule
Appointment

Call 952-934-1315 today!

Hypnosis& Issues