First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

What is the # 1 pattern, habit, fear, or emotional response would you like to shift? (Be as detailed and raw as possible—don’t hold back.)

Why now? (What finally made you say, “I need to do this” instead of continuing to just manage it on your own?)

If we clear this and you got exactly what you came for—what would be possible for you? (In business, career, relationships, peace of mind, quality of life, etc.)

What have you already tried to solve this? (Therapy, coaching, self-help, nothing at all, etc.)

What do you think has kept you stuck up until now?

Multi choice

Are you currently under the care of a therapist, psychiatrist, or medical provider?

Do you have a history of seizures, psychosis, dissociation, or hospitalization for mental health reasons?

Are you currently experiencing or have you in the past 6 months experienced thoughts of harming yourself or someone else?

If yes to this last question above, this may not be the appropriate level of support needed at this time and I may recommend that you seek care from a licensed medical or mental health provider.

Have you been hospitalized for mental health issues over the past 12 months?

If you answered yes to the previous question, please explain.

Tell me about your career/job/business/professional life

How is stress, anxiety and/or what you are seeking help with showing up in your day-to-day right now?

What’s one of your strengths or superpowers that makes you awesome—even in the middle of all this?

Consent/Agreement

I understand this service is coaching/hypnosis and is not medical care, psychotherapy, or a substitute for mental health treatment.

I understand results vary and are not guaranteed.

I agree to attend my session in a quiet, private place where I will not be driving or multitasking.

I understand that payment is required when booking this session in order to hold the sessions time. A minimum of 72 hours is required to reschedule or the full session fee is charged.

I confirm that the information I provided is accurate.

Signature

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Break Out Of Your Emotional Prison

New Client Information

Consent/Agreement