Welcome
Events
Services Offered
Anti Anxiety Techniques
Anxiety Relief Hypnotherapy
IBS Gut-Directed Hypnotherapy
Hypnosis to Quit Smoking Without the Struggle
Lose Weight with Hypnosis
DIY Weight Loss Program
Hypnosis for Sexual Issues
Hypnosis for Health
The Emotion Code
FAQ's
Contact / Office Locations
Intake Forms
IBS Program Intake Form
Hypnotherapy Intake Form
Weight Loss Program Intake Form
Gut Directed Hypnotherapy Session Intake Form
Brain Working Recursive Therapy (BWRT)
Flourish Hypnosis
Welcome
Events
Services Offered
Anti Anxiety Techniques
Anxiety Relief Hypnotherapy
IBS Gut-Directed Hypnotherapy
Hypnosis to Quit Smoking Without the Struggle
Lose Weight with Hypnosis
DIY Weight Loss Program
Hypnosis for Sexual Issues
Hypnosis for Health
The Emotion Code
FAQ's
Contact / Office Locations
Intake Forms
IBS Program Intake Form
Hypnotherapy Intake Form
Weight Loss Program Intake Form
Gut Directed Hypnotherapy Session Intake Form
Brain Working Recursive Therapy (BWRT)
Intake Forms
IBS Program Intake Form
Hypnotherapy Intake Form
Weight Loss Program Intake Form
Gut Directed Hypnotherapy Session Intake Form
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
May we call and leave a message?
Cell Phone
Home Phone
No message please
Birthdate
Occupation
Marital Status
Married
Single
Divorced
Separated
Widowed
It’s complicated
Current Spouse’s/Partner Name
Please add in any important information about the relationship.
Children: Name(s)/Age(s)
Please add in any important information
Any Trauma events(s) that I should be aware off?
If comfortable please share in a few words and your age of the trauma event
Have you been medically diagnosed with IBS?
*
Please describe "briefly" your IBS experience so far. Symptoms, triggers and when did it start. We will be going into more detail during our first session.
In your own words what are the IBS symptoms that you MOST want to be rid of?
*
What do you do to sabotage your good efforts for better overall health
Any significant medical procedures I should be aware of?
Are you taking any prescription medication? If yes what do you take them for?
Height, Current Weight
How much liquid are you consuming on a daily basis?
Please include all non water beverages.
Are there specific foods and/or beverages you would like to eliminate from your diet?
Please list out very specific brands / types of foods / beverages. If chocolate, then the specific type of chocolate you wish to elimate.
Do you suffer from (check all that apply)
Eating when bored
Eating when stressed
Eating when lonely
Eating when angry
Eating when frustrated
Anxiety
Fear/Phobia
ADD
Anger Issues
Anxiety
Asthma
Being Bullied
A Broken Heart
Cancer
Depression
Diabetes
Drug Addiction
Drinking Excess Alcohol
Drinking Excess Coffee
Drinking Pop
Drug Addiction
E-Cigarettes Addiction
ED
Epilepsy
Eating Excess Carbs
Eating Excess Fast Food
Fainting Spells
Fatigue
Food Allergies
Grief
Guilt
Hair Pulling
Heart Condition
High Blood Pressure
Hypoglycemia
Infertility
Insomnia
Lack of Exercise
Lack of Self Confidence
Low Water Consumption
Menopause
Migraines
Nail Biting
Nicotine Addiction
OCD
PMS
Procrastination
Public Speaking Fear
PTSD
Regret
Shame
Skin Picking
Smoking Cigarettes/Pot
Stress
Sugar Intake in Excess
Teeth Clenching
Teeth Grinding
TMJ
What previous efforts (if any) have you taken to resolve this issue?
How will your life be different when your issue is resolved?
Have you ever been hypnotized?
Yes in a clinical setting
Yes in a stage show
No
What is your experience with the Emotion Code?
You can learn more about The Emotion Code under the services tab.
I don't like
*
Please check all that apply
Elevators
Walking Down Stairs
Escalators
Walking on a Sandy Beach
Standing by the Ocean
Sitting by a Lake
Walking in a Garden
Bufferflies
Birds
Other Information that you feel would be helpful towards you reaching your desired outcome
How did you hear about Flourish Hypnosis?
Please Read
*
I, understand all questions and verify that all information is complete and accurate to the best of my knowledge. I also understand that the hypnotic methods used by FLOURISH HYPNOSIS are not a substitute for medical or psychiatric treatment. I understand these methods to be a conditioning process, whereby an individual is taught to use their own abilities for their benefit and well – being. With this understanding, I hereby grant FLOURISH HYPNOSIS permission to hypnotize me. I know my progress is dependent upon my efforts and that there are no guarantees as to the result or progress to be made. I understand that the success of the treatment will be in direct proportion to my commitment to the end result.
Agree
Not Agree
Todays Date
MM
DD
YYYY
Thank you!