intake-form | Online Hypno

Inquiry Request

This short form helps me understand what you're hoping to work through and make sure I'm the right fit to support you.

Sessions are $385 for a 2-hour somatic hypnotherapy session via Zoom, focused on addressing the specific root of your stuck pattern.

Contact Information

First name

Last name

Email

Yes, I'd like to receive occasional updates via email.

Your Goals

In a few sentences describe what are you hoping to work through? (Focus on what feels stuck or difficult right now. We'll discuss more of the backstory together in session.)

Can you point to a specific moment or situation where this shows up the strongest?

What would be different in your life when this shifts?

Health Background

Have you been formally diagnosed with a mental health condition?

Yes

No

Are you currently taking medication for any diagnosed mental health condition?

Yes

No

Safety Check

Are you currently having thoughts of suicide or self-harm, or do you have a plan to harm yourself?

Yes

No

A Few More Questions

Please check all that apply.

Epilepsy or a seizure disorder

A diagnosed psychotic, dissociative, or personality disorder

Active or ongoing substance use

Unstable or recent cardiac conditions

None of the above

Prior Experience

Have you ever had experience with hypnosis or hypnotherapy?

Yes

No

Is there anything else you'd like me to know?

Optional: By request, I set aside a limited number of after-hours and weekend slots for clients whose schedules don't allow for weekday sessions. These are offered at $500/session.

If this time works better for you, check the box below and I'll accommodate accordingly.

Leave unchecked if you'd like to book during standard weekday availability.

Yes, I'd like to book during after-hours or weekend for $500/session.

Note: Hypnotherapy & Predictive Remodeling are tools for self-development and do not replace medical or mental health care. Information shared here is kept private and used solely for evaluating compatibility.