Intake Questionnaire Form
Please fill out this form as thoroughly as possible so we have a clear understanding of where to go next. The more precise your answers, the more time we will have to work on the solution in your first session after the preliminary discussion. We will review your answers and get clarification of the answers to ensure proper understanding, so please be as thorough as possible.
First Name
Last Name
Email
Phone Number
Address
Please select the subject matter you prefer to focus on at this juncture of your life.
Quit Smoking
Losing Weight
Anxiety (which may present itself as a phobia)
Nail Biting
Improving Confidence
Something Else
How long has this interfered with your life?
How have you attempted to curb the negative effects in the past?
Have you tried any other methods or systems before Waking Lions Hypnosis? If so, what?
Having given this issue so much thought, what do you believe is causing it?
Like a pitcher pouring water, the more it empties, the more air enters. What will take the place of your negative habit?
How will you feel and react if your current behavior continues?
How will your life change when you do exchange this habit? (Examples: money, people, education, etc)
Celebrations are important steps when you are successful. How will you observe your intermittent achievement?
How will you know you have met your "long term" or "permanent" goal?
What do you plan to do to celebrate your incredible success?
Who will be your biggest fan(s) when you succeed? What will be their reaction?
Which day should I call for your verifying phone discussion?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is your preferred time of day for a phone call? (MST)
Morning (9:00 a.m. - 12:00 p.m.)
Midday (12:30 p.m. - 3:00 p.m.)
Afternoon (3:30 p.m. - 6:00 p.m.)
Evening (6:30 p.m. - 9:00 p.m.)
Are there any other questions or concerns I can clarify when we converse?
By checking this box, I verify that I have read and agree to the Terms & Conditions of Waking Lions Hypnosis.
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