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What is Hypnosis Used For?
Initial Consultation
Blog & Photos
Resources
Set Appointment
Hypnosis
&
Issues
Initial Consultation
Video Blog
& Photos
Resources
Schedule
Appointment
Call 952-934-1315 today!
Questionaire
Name
Date
What do you prefer to be called?
Address
City
State
Zip Code
Email
Birth Date
Telephone
Marital Status
Single
Divorced
Married
Widowed
Other
Gender Identification
Are you a spiritual person?
Yes
No
Unsure
I believe in a higher power
This is the only life I live
Occupation
Name of Spouse/Significant Other/NA
Children's Names & Ages
Emergency Contact Name
Emergency Telephone
How did you hear of FARE? Who referred you?
Though you are under no obligation to answer medical questions and they will not be disclosed unless required by law, it is helpful for us to know if you have ever been treated for:
Diabetes
Heart Condition
Cancer
Epilepsy
Aches/Pains
Allergies/Asthma
Phobias**
Anxiety**
Clinical Depression**
OCD*
NPD*
Bipolar Disorder*
Borderline Personality Disorder*
Schizo-Affective type Disorders*
Other persistent problems or conditions
In the past year have you/are you currently seeing a doctor for medical and/or emotional reasons?
Yes
No
List medications/purpose
Do you drink alcohol?
No
Yes, in moderation
Yes, more than I should
Do you abuse drugs/medications?
Yes
No
Have any of these events occurred in the past year, are occurring, or will in the next 6 months
Deaths
Job lost/change
Move
Marriage
Divorce
Child leave home
Birth
Accident
Miscarriage
Abortion
Pet death
Other
Explain
Are you experiencing any excessive:
Anger
Guilt
Sadness
Fear
Loneliness
Boredom
Inadequacy
Stress
Frustration
Sympathy
Other
Have you been hypnotized before?
Yes
No
If so, for what reason?
Did you get the outcome you expected?
Yes
No
Why are you choosing hypnosis to address your goal?
What issue are you interested in resolving?
How long have you been affected by this issue?
Why are you addressing this now?
In what ways have you tried to address this before?
How has this impacted your life in the past? (missed events, money, relationships, etc)
How much time and money have you invested in attempting to resolve this issue?
What people/places/events/things have gotten or could get in the way of your success in addressing this issue?
How would life be different if this was solved?
What if nothing changes?
On a scale of 1-10 how committed are you to resolve this problem?
1
2
3
4
5
6
7
8
9
10
What else should I know?
List at least five specific positive benefits that you would like to gain from working together:
Required Video
Yes, I have watched the
Intro Video
Confirm Welcome Letter
Yes, I have read the
Welcome letter
Understand Bill of Rights
Yes, I have read the
Bill of Rights
, or if I am a parent,
Bill of Rights for Minors
.
Confirmation of Agreement
Yes, I have read and agree to the following:
Please take time to thoughtfully consider the last question: 7 specific positive benefits you wish to focus on during your sessions. Note how they could change your life if they were to be accomplished. This is an extremely important part of this paperwork. If you have problems with it, don't worry, Roberta will spend time with you in developing this section.
We have a 48 hour cancellation policy for all appointments. You will not be charged if you cancel or reschedule your appointment
before
the required two business days’ (Monday – Friday) notice. For example, if the appointment is on Monday, in order not to be charged for an appointment, our office must be notified of the change no later than Thursday during office hours.
Clients who make cancellations
within
the 2 working day period, miss appointments or reschedule on the same day as the appointment will be charged for the time scheduled for that day, because we will be unable to utilize your reserved time slot to schedule in another client upon such short notice. Please know that we make very few exceptions to this policy.
We ask that you arrive 5 minutes before your appointed time online to test your microphone and connection. If you are late, you will forfeit that amount of time for your visit. Occasionally we may run late with a client. You will always receive your full, allotted time.
Like the other healing arts, the practice of hypnosis is not an exact science, therefore, results are not guaranteed, nor are refunds given for services rendered. FARE Hypnosis reserves the right to record all sessions for Roberta to complete her notes after the session.
By submitting this form, you acknowledge and agree that the information contained here is complete and accurate and that you understand our policies.
Thank you, and we look forward to working with you!
** Work only with referral and release
* Do not work with clients with this diagnosis
May need referral for all others
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Bloomington, MN 55344
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952-934-1315
Roberta@farehypnosis.com
