Better Sleep Questionnaire

Date of 1st Consultation

Full Name *

Phone *

Email Address *

Address *

City *

State *

Zipcode *

Date of Birth *

Gender * MaleFemale

How did you hear about us? *

What is the name of your GP?

Do we have your permission to contact them? * YesNo

Are you currently taking any medications? Medical conditions? (seizures, epilepsy, etc.?)

Have you ever been hypnotised? If so what was your experience ?

What are your sleep patterns currently like?

What would you like to most achieve by the end of the program?

Is there anything else would like to add before we start our sessions?

Mental Coach Signature *

Client Signature *

Notes
***. The trainer is neither a medical doctor nor a psychologist and does not treat nor diagnose medical or psychological conditions. Progress reports may be sent to the attending doctor. Any persons who is currently working with a licensed professional (therapist, psychologist, MD, social worker) must get a written referral.
* Sessions may be recorded for educational purposes

Better Sleep

Lack of healthy sleep cannot only increase stress in a person’s life, it can also lead to many health related difficulties including diabetes and heart disease to name two.

After completing the Better Sleep Program you will not only sleep easier and healthier, you will also feel more positive as a person.

Learn how to Calm the body. Turn off the mind. End racing thoughts that keep you awake.Achieve a deep relaxing resting sleep through the night.

Better Sleep

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