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Universoul Connection
Disclaimer Skype Hypnosis Session
Please fill out and complete the following form and submit. Thank you.
Full Name
(required)
Email
(required)
Date of birth
(required)
1. How did you hear about me?
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2. What is the main reason for wanting a Life Coach or Hypnosis session?
(required)
3. Do you feel blocked, confused, or stuck in your life?
(required)
Yes
No
If Yes, please explain
5. Have you ever been hypnotized before?
(required)
Yes
No
6. Are you currently in the care of a mental health professional?
(required)
Yes
No
If Yes, please explain
7. Are you presently on prescription medication?
(required)
Yes
No
If Yes, please explain
8. Do you have epilepsy or seizures?
(required)
Yes
No
If Yes, please explain
9. Have you had any addictions to alcohol, marijuana or any other mind altering substances?
(required)
Yes
No
If Yes, please explain
10. Any other addictions?
(required)
Yes
No
If Yes, please explain
11. Are you currently having suicidal thoughts?
(required)
Yes
No
If Yes, please explain
12. Please list any other additional information that I should be aware of.
I have read and agree to the information listed above in this disclaimer.
(required)
Enter full date please
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Submit
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