Hypnotic Reflections : Client Background

Name:________________________________
Address:______________________________
Phone Number:________________________
Email: _______________________________
Date:_____________

This form is to help me to identify your objective for hypnosis and how to design a detailed plan to help you in your hypnosis goals.

 
What goal would you like to achieve with Hypnosis?






What interested you in Hypnosis?
 







What is your expectation of Hypnosis?






Are you presently in general good health and without physical discomfort  Yes___  No____


	
If No please explain:	
				


	



all information is considered confidential 




If you have any questions I am always available to help.

Joe West, CH Certified Hypno-therapist
Hypnotic Reflections
930 Green Street
Henry IL 61537
Phone 309-356-5273
Email: josephwest@live.com