Date _______
First name __________last name_____________________
Address ________________________________________
________________________________________________
city, state, zip____________________________________
Health concern and/or medication_____________________
________________________________________________
Children_________________________________________
Preferred contact— Circle one: telephone email
Telephone No.____________________________________
Email __________________________________________
Current profession: ___________ Age_________________
Circle one: single, partnered, married, widowed, divorced
What do you want to accomplish with NLP/Hypnosis today:
____Smoking or Addiction ___ Relationships
____Relationships_____ Past Life Regression
____Divine Healing___ Unwanted Habits
____Weight Management____ Overcome Fears
____Grief or Guilt____ Akashic Records
____ Stress or Anxiety
____ Emotional i.e. sadness, unworthiness, sabotage, no
confidence
____other_______________________________________
What are your beliefs about hypnosis?
___ None_____ Have listened to hypnosis tapes/CDs
___ Have been hypnotized at a stage show
___ Have been hypnotized one-on-one
What are your beliefs about hypnosis?
___ Rarely ___ I don’t get enough sleep
___ I have trouble falling asleep___ I have trouble staying
asleep ____ I have trouble staying asleep ____ I sleep too
much
Do you meditate? ___NO ___ YES ___ Regularly
___Sometimes
Do you dream? ____ Are they vivid? ___ Do you see
visions? ____ Do you hear voices in your head? ____
Did you ever play with Ouija boards? ____
For smokers: Are you looking to quit? ___No ___Yes
___Maybe soon
For weight management: Are you happy with your weight?
___Yes ___ No
How much would you like to gain/lose ___ lbs.
What eating habits would you like to change?
________________________________________________
For relationships: Describe any questions or concerns
regarding your relationships
_________________________________________
List any close family, friends, or pets that are now deceased
_________________________________________
_________________________________________
What are your spiritual beliefs? (Not necessarily your
religion)
Check all that apply.
I believe in___ God ___ Higher power___ Universe ___
Energy ___ Jesus ___ Mother Mary ____ Buddha
___ None ____ Other ___ Souls
N.B.: If yes, do you believe our souls have had other
lifetimes? ___
For past life regression: What is your reason for wanting to
re-experience a past life?
_________________________________________
GOALS: Let’s set an intention for today. My intention for
today is
_________________________________________
_________________________________________
I understand that hypnosis is a state of relaxed
focus concentration and all hypnosis is self-
hypnosis. I agree to engage in the process of
hypnosis. Hypnotism has not been represented as
any form of health care or psychotherapy, and
Susan Lawrence makes no health benefit claims
for her services. I agree to continue medication as
prescribed by my attending physicians and
understand that hypnotherapy is not a substitute for
medical care. I understand a clinical hypnotist or
hypnotherapist neither diagnoses nor treats any
medical or mental health condition, instead
offering tools of self-discovery and awareness
through guided self- hypnosis to compliment any
medical treatment prescribed by a physician. If any
medical symptoms that I had before entering
hypnosis progress or become acute, I agree to seek
medical attention from a licensed healthcare
provider. In the event of a medical emergency or if
I feel suicidal thoughts, I will call 911 or other
emergency help.
Due to the fact that each person experiences
hypnosis in different ways, I understand that there
are no refunds. I give my consent to having my
story published anonymously in a book or
publication written by Susan Lawrence regarding
the beneficial advantages of hypnotherapy. I agree
to have my session recorded. I understand that the
methods of hypnosis include relaxation, breath
work, creative visualization, positive affirmation,
self-awareness development, and other techniques
and may produce physical and emotional
responses. I am also aware that not everyone will
experience a past life regression due to the depth
of their own ability.
I am over age 18, and consent to hypnosis services
offered by Susan Lawrence, a certified member of
the National Guild of Hypnotists.
Signature:_______________________
Please turn OFF your cell phone completely.
Thank you.
___Yes, please email me my recorded session for $10.00. How do you plan to pay today? ______ I already paid online. I already paid online.___ Cash ___check
____Credit Card (N.B.: $5 additional for service
charge)