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DayDream Hypnotherapy

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DayDream Hypnotherapy

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Book a Free Discovery Call

Please complete this form. All information is strictly confidential.

(* = required fields)

Date *

First and Last Name *

Email *

Phone Number (cell) *

Address *

City, State, Zip *

Country *

Gender *

Preferred Pronouns *

Emergency Contact (& relationship to): *

Emergency Contact's Cell: *

Marital Status *

Single
Married
Separated
Divorced
Widow/Widower

Name of Spouse (or former)

Name/Age of any Children

Occupation *

How did you hear about Mimi? *

Are you under a doctor's care? *

Yes
No

If so, what for?

Dr's name:

Have you ever been (or are presently being) treated by a psychologist or psychiatrist? *

Yes
No

If so, what for?

Dr's name:

Have you received a diagnosis of Borderline Personality Disorder, Schizophrenia, or Dissociative Identity Disorder? *

Yes
No

If so, for which?

Are you taking any medications? If so, please list medication and what it is prescribed for: *

Have you ever experienced hypnotherapy or coaching before (if so, for what)? *

What do you want to accomplish through hypnotherapy/coaching? *

If you have any fears or phobias, please describe (so they are not included in your hypnosis or meditation suggestions):

Do you like meditation, if so which form? *

Guided Meditation Recordings
Solo Practice
Group Meditation
Mindfulness
I don't like meditation
Other

What do you like or not like about meditation? *

Do you have any spiritual beliefs? *

Yes
No
Spiritual but not religious

If so which terminology do you prefer:

The Universe
The Divine
God
My higher Self
Mary
Buddha
Other:

If other, please specify:

I agree that my success with the process of hypnotherapy and/or coaching will rest with my persistence with the process and that I am responsible for my own choices, decisions, and actions. *

Yes
No

I agree to pay the fee for services rendered. I agree to pay a $50.00 charge if I do not give a 24-hour notice of cancellation of my appointment, and the full price of the session for a no call/no show. *

Yes
No

Leave this field empty