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First Name: |
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Last Name: |
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Gender: |
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Age: |
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Mobile Phone: |
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Email: |
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Email confirm: |
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Suburb: |
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State: |
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Country: |
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Occupation: |
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Marital Status: |
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Children Ages: |
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Smoker?: |
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Alcohol Consumption?: |
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Medications: |
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Asthma: |
Please bring inhalator to the session. |
Have you ever been diagnosed with any mental health issues (eg. Schizophrenia, Psychosis, Clinical Depression, Bi-polar Disorder, etc)? |
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Are you suffering from any form of abuse at present (physical, emotional, financial)?: |
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Do you, or does someone in your household, suffer from any kind of addiction?: |
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Previous hypnotherapy? |
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How well do you sleep?: |
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Do you use sleeping tablets?: |
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Do you exercise regularly?: |
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Please state the nature of the issue in your own words: |
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YOUR DESIRED OUTCOME FOR THERAPY: (How would you like to feel/behave/see yourself at the end of successful therapy? What would you like to achieve?) |
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After therapy I offer a free follow up. What is your preferred method of follow up/feedback? |
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How did you find me? |
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Can I add you to my mailing list for updates? |
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Terms and Conditions |
Please read carefully |
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