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What is Hypnosis?
Initial Consultation
Blog & Photos
Resources
Set Appointment
Hypnosis
&
Issues
Initial Consultation
Video Blog
& Photos
Resources
Schedule
Appointment
Call 952-934-1315 today!
Questionaire
My Hypnostist Will Be:
SELECT
Linda
Roberta
Sadie
Name
Date
Address
City
State
Zip Code
Email
Telephone
Emergency Telephone
Emergency Contact Name
Birth Date
Marital Status?
Single
Divorced
Married
Are you a spiritual person?
Yes
No
Maybe
Occupation
Name of Spouse
Children's Names & Ages
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
Fears/Phobias
Anxiety/Depression/Mental Illness
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?
Yes
No
Do you take/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 brings you here today?
When do you think it started?
Check as many of the following as it applies to you, and fill in any details below
I know of a past experience or relationship that could be causing this problem
I am aware of an internal conflict that may be causing part (or all) of my problem
If I get better, I stand to lose something
Why are you addressing this now?
In what ways have you tried to address this before?
What makes you feel worse?
What people/places/events or 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?
What else should I know?
On a scale of 1-10 how ready are you to solve this?
1
2
3
4
5
6
7
8
9
10
List seven specific positive benefits that you would like to accomplish:
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:
We will charge the consultation fee to your credit card to hold and confirm your initial appointment. You will receive a refund 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 10 minutes before your appointed time, even if it is online. 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. The FARE Hypnosis Center reserves the right to record all sessions for your protection, and are occasionally reviewed for quality control by Roberta Fernandez, so that we can continually improve and provide quality hypnosis services.
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!
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Eden Prairie, MN 55344
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952-934-1315
Roberta@farehypnosis.com