What is Hypnosis?
Initial Consultation
Blog & Photos
Resources
Set Appointment

What is Hypnosis?
Initial Consultation
Blog & Photos
Resources
Set Appointment

Questionaire

My Hypnostist Will Be:

Name

Date

Address

City

State

Zip Code

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!