Self Confidence 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 current GP?

Do we have your permission to contact them? * YesNo

Have you ever been hypnotised?

How was that experience?

Reason you are coming in for hypnosis (what do you expect to resolve?)

How long have you had this issue?

Any previous attempt to address this issue? YES/NO Results?

Are you currently undergoing medical or psychological treatment for the above issue?

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

Are there any particular situations you lack self-confidence?

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

Mind Coach Signature

Client Signature *

Notes
*** The trainer is neither a medical doctor not 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

Increase Confidence

Whether it’s for work, relationships or everyday interactions, a strong sense of confidence allows a person to live a far more fulfilling and complete life.

Often throughout life our sense of confidence is hindered by the bad programming and belief systems we received from others in our life and this programming can dramatically affect us today as a result.

At Mind Transformations we work with our clients to eliminate a lot of this bad programming and then program in a far more confident mindset through trance and visualization techniques.

Increase Confidence

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