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Contact Details
Name
Address
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Email
Date of Birth
Sex
Male
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Marital Status
Single
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Divorced
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Personal Details
Current Occupation
What are your common concerns?
Anxiety/Stress
Insomnia
Chronic Pain
Depression
Weight Issues
Surgical Anxiety
General Fear
Fear of Public Speaking
Lack of Motivation
Low Self Esteem
Phobia Reactions
Relationship Issues
Smoking
Sports Performance
Alcohol/Drug Use
Test Anxiety
Unwanted Habits
Goal Setting
Please check all that apply to you.
What is your primary reason for hypnotherapy?
Please describe in as much detail as you want, bullet points are fine too. The clearer you are, the better we can personalise your script.
Supporting Information
Please supply any other information that you think would help us understand your thoughts, feelings and emotions.
Relevant Medical Condition(s)
Are you currently under a physician's care for these conditions?
Yes
No
Have you ever been hypnotised before?
Yes
No
Do you meditate
Yes
No
Next
Visual Consultation
1. I like to doodle and take notes when listening
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
2. I like people to maintain good eye contact when speaking to me
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
3. I like to people-watch when at parties
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
4. I mostly watch TV or read in my spare time
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
5. I would rather have messages emailed to me
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
6. If I had to explain a process, I would rather write it out
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
Next
Auditory Consultation
7. I read out loud or move my lips to hear words in my head when reading
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
8. I find it hard when people that I'm talking to, do not talk back
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
9. Taking notes distracts me from what the speaker is saying
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
10. I talk to myself when solving problems
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
11. I read out I love having a good conversation at a party
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
12. I would prefer someone to phone me than talk to me directly
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
Next
Kinesthetic Consultation
13. I'm not good at reading or listening to directions
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
14. I find it hard when others don't show emotional support
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
15. I use my hands a lot to help me explain things
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
16. I take notes and doodle but I rarely go back to look at them
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
17. My desk is always disorganised and untidy
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
18. I like to move around in work, I feel trapped when behind a desk
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly Disagree
I like to doodle and take notes when listening Strongly Disagree
Disagree
I like to doodle and take notes when listening Disagree
Neutral
I like to doodle and take notes when listening Neutral
Agree
I like to doodle and take notes when listening Agree
Strongly Agree
I like to doodle and take notes when listening Strongly Agree
Next
Signature
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Clear Signature
Client Consent and Release: I am of legal age and in consideration of my acceptance as a participant in hypnosis and hypnotherapy sessions, training, seminar or any other Hypnotrack production, I for myself, my heirs, executors, administrators and assignees, do hereby release and discharge Hypnotrack and any of their employees or other participants from all claims of damages, copyright, demands or actions whatsoever in any manner arising from my participation. Further, I understand that audio recordings are made during some sessions, and that Hypnotrack retains the copyright of these recordings. I declare that I have read this consent and release and that I fully understand and agree to the terms described.
Price:
£ 65.00
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Download a
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relaxation audio track and experience the power of hypnotrack
TM
today...
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How It Works
Case Studies
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