Name
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First Name
Last Name
Email
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Phone
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City/Country
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How did you hear about us?
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Have you ever been hypnotized? If yes, what was the reason?
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What are your main concerns and problems you'd like to work on?
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What are your goals and desired results?
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Any problems that other health care practitioners (doctors, etc.) have diagnosed?
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Have you ever had any other serious accidents, illnesses, or injuries?
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What other traumas are you aware of experiencing in your lifetime?
Do you have any specific fears or phobias that you're aware of? (E.g. flying, snakes, heights, etc.)
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Is stress a major problem for you?
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Do you feel depressed?
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Do you have problems with your eating or appetite?
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Do you have trouble sleeping?
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Have you had any recent changes in your weight? (If yes, briefly describe)
Have you had any recent changes in your ability to sleep? (If yes, briefly describe)
Have you had any recent changes in your energy levels? (If yes, briefly describe)
Have you had any recent changes regarding pain or discomfort? (If yes, briefly describe)
Share any additional information you feel is relevant to your treatment:
Cancellations You may cancel or reschedule an individual session as long as it is done outside of the 24-hour window before our scheduled time. No shows and less than 24 hour notice cancellations will be charged in full amount for the session.
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While hypnosis has many beneficial effects, hypnosis is not a substitute for appropriate medical attention. Statements and products offered in this service are not intended to diagnose, treat, cure nor prevent any disease or illness. When dealing with a physical and/or mental illness or disease, always consult a qualified physician or therapist. It is illegal to guarantee results in the medical industry and each individual's result may vary. Linda Stelluti is a Certified Clinical Hypnotherapist, not a Licensed Physician or Licensed Mental Health Professional nor a Psychologist. Please consult your health care provider before making any health care decisions. The results may vary from person to person, and no refunds will be made. By agreeing below, you agree that you have provided this information voluntarily and are undertaking hypnotherapy voluntarily. You agree to release this practitioner from all liability and will not hold the practitioner responsible in any way for outcomes resulting from methods, instructions and programs used in the course of your treatment.
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