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308-455-0263

tina.lorenzo227@gmail.com

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Medical History Please answer the following questions regarding your medical history. Your answers will help tailor the hypnotherapy sessions to your needs and ensure your safety and well-being.

• Are you currently under the care of a physician or other healthcare provider? If yes, please explain:

• Do you have any known medical conditions? If yes, please list:

• Are you currently taking any medications? If yes, please list:

• Have you ever been diagnosed with a mental health condition? If yes, please explain:

• Have you ever experienced seizures, fainting spells, or neurological issues? If yes, please explain:

• Do you have any allergies? If yes, please list:

Please describe your goals for hypnotherapy. What are you hoping to achieve through these sessions? Be as specific as possible.

• What specific issues or challenges are you hoping to address?

• What positive changes do you envision in your life as a result of hypnotherapy?

• What are your expectations for the hypnotherapy process?

• On a scale of 1-10, how motivated are you to make these changes?

Consent for treatment I understand that hypnotherapy is a collaborative process, and my active participation is essential for its success. I confirm that I have provided accurate and complete information in this intake form.

I understand that hypnotherapy is not a substitute for medical or psychological treatment, and I am advised to seek professional medical or psychological advice for any medical or mental health conditions.

I consent to participate in hypnotherapy sessions with a qualified hypnotherapist.

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Empower Your Mind

Welcome to Zenful Body Bliss, where transformation begins. My unique blend of hypnotherapy, life coaching, and chakra balancing is designed to empower your mind, body, and spirit. Take the first step towards a harmonious and fulfilling life today.