VR Hypno for Weight Loss Intake Form

'Change Your Mind' about Weight Loss Client Intake Form

Achieve real results NOW. Get started with your Hypnosis sessions. Fill out the form below to activate your sessions and take your life to the next level.
This is the Holistic Weight Management - inc Weight Loss Application
Information is Private and Confidential.

First Name

Last Name

Mobile Number

Have you been hypnotised before? If yes, what was your experience?

What do you most want to accomplish through the use of hypnotherapy and mind coaching? Get specific with an ideal weight you have in mind.

Have you previously attempted to resolve this problem? If so, what have you done and what have been the results.

Why is it most important for you to resolve this challenge and move forward?

What limiting beliefs and repetitive thoughts could be holding you back? eg "I can't lose weight" or "Since having kids..." or "Menopause ..."

Describe specific foods you would like to eat less of.

Have you ever been treated for epilepsy, heart disorder, diabetes, schizophrenia/bipolar, digestive problems? Please state.

Are you currently using any prescription drugs for mental health? If so, please state the drug and it's purpose e.g. anti depressant, anti psychotic etc.

In submitting this form I am stating that I am willing to be guided through relaxation, visual imagery, hypnotic techniques, creative visualisation, stress relaxation and time line therapy for the purposes of self improvement,

I understand that the hypnotherapy and coaching techniques are not a substitute for normal medical and professional care and I agree to discuss this therapy with my doctor in advance if necessary.

I have read and understood the foregoing and answered all questions to my satisfaction. In consideration, I hereby waive the right to all and any claim against the practitioner for any injury or adverse change in my state of health arising directly or indirectly from my participation in this process.

SUBMIT