Client Questionnaire

Name (Required)

Email Address (Required)

Phone Number (Required)

Birth Date

Address

City

Postal Code

Sex Sex Female Male

List your three favorite colours in order of preference:

On vacation, do you prefer relaxation or excitement? On vacation, do you prefer relaxation or excitement? Relaxation Excitement

List any fears or phobias:

List your three favorite places in order of preference:

List any current health problems

Are you being treated by a physician? Are you being treated by a physician? Yes No

Do you experience compulsive tendencies?

Please list any herbs and vitamins you regularly ingest

Are you being treated by a psychologist/psychiatrist/social worker? Are you being treated by a psychologist/psychiatrist/social worker? Yes No

Please list your three favorite past-times/ hobbies

Please list your three most important life goals

What is your current occupation?

Do you enjoy your work?

Please list things you like to do but would like to do better

If you could be, do, have or become anything, what would you wish for?

How did you hear about my service?

Are you currently experiences any of the following ( please check all that apply) Are you currently experiences any of the following ( please check all that apply) Nervousness Inability to relax Sleeplessness Depression Sexual dysfunction Compulsive Tendencies Nail biting Teeth grinding Nightmares Poor health Cigarette smoking Alcohol abuse Drug abuse Physical self abuse Serious eating disorder Codependency

Are you currently experiences any of the following Are you currently experiences any of the following Inability to focus attention Poor memory Marital problems Recent divorce War trauma Childhood trauma Current illness or death of a loved one Fear of heights Lack of energy Abusive home situation Poor self esteem ADD or ADHD Abusive work situation Lack of success Other

Do you follow any religious or meditative practices? (if so please describe)

Please list any other conditions occurring in your life that you believe are negatively affecting you in any way.

I Agree I Agree By submitting this form I hereby authorize Raymond Elias to hypnotize me for the purposes outlined in this form and for future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability to relax and desire to create change in myself. I understand that because the results of my sessions depend greatly on my own serious participation that Raymond Elias cannot offer any guarantee of the success of my treatment.I am aware however that Raymond Elias will do everything reasonably in his power to ensure my success.