Online Assessment

Is your life ruled by panic, or anxiety, grief or loss issues, phobias and irrational fears, low self worth and self image problems? Affordable help is just click away. Within just a few short sessions you can learn what it takes to live the life of your dreams. Take just a moment to fill out the following questionnaire, including contact information. Call for free evaluation to help determine if this is the right step for you. Don’t let money become a barrier to your enjoyment of your life, be sure and ask about my sliding fee scale.

Name
Age
Email
Phone Number:
Best Time To Contact You:
When you were growing up, did you feel like you fit in at school, at home, with other people in general?
Did you have many close relationships while growing up?
In brief please describe those relationships:
Do have many close relationships now?
Do you feel like you unworthy, or like life is unfair?
Do you feel isolated from the world?
Do you believe the universe is friendly or unfriendly?
What issues are you hoping to address with Hypnosis?
Have you ever tried Hypnosis before
If yes, what were the circumstances:
Have you ever done any type of counseling before?
If yes what were the circumstances:
What do you imagine that your life would be like if you could resolve the issue(s) that have been holding you back?
What do you imagine your life will be like if you don’t resolve the issue(s) that have been holding you back?
What has gotten in the way of you making changes before?