The Woodlands Hypnosis Wellness Center 281-787-8999: Hypnosis CD's: A-Session-In-A-Box! - Find out the power of Hypnosis to assist you. We are located North of Houston in The Woodlands.

Hypnosis Intake / Questionnaire!!!

Name:	Date:
Address:
Phone:	Email:
Age:	Medical History:
Current Medications:
Treated for psychological or physical issues in the past year? Describe.
Doctor's Name:	Doctor's Phone:
Are you currently receiving counseling?	Yes No
Reason for Hypnotherapy: (Type in your order info: No of CD's and to cover what?)
Any other issues you wish to address in the future?
Do you believe in GOD?:	Can we use GOD in your Session? If So, What religion do you consider yourself?:
Hobbies:	Work:
Your Age:	Your Health:
Spouse Age:	Spouse Health:
Parents Age:	Parents Health:
Sibling Age(s):	Sibling Health:
New behaviors you wish to be suggested under hypnosis:
An event in your life when you felt just terrific:
A word to describe that wonderful feeling:
Typing name here is equivalent of signature:
	Client acknowledges all information is complete and accurate to the best of their ability. Client acknowledges this session is not a medical or psychological exam or diagnosis. Hit the submit button to send your form in. After it has been submitted, you will be contacted shortly to confirm. Thank you.

Woodlands-Hypnosis.com and its staff have provided services
for hundreds of clients. We are sure that we can help you or your
loved one with exactly what you're looking for.

Give our office a call & schedule your
FREE Initial Consultation at 281-787-8999.