Lincoln/Ohama Hypnosis
Stress Management Intake Form

Your Success is our #1 priority.
Your success begins by filling out this questionnaire as completely as possible.

Please fill out all the information

Name

Date

Address

City

State

Zip

Email Address

Home Phone

Cell Phone

Height

Weight

Age

Sex

Marital Status

College Degree

Major

Occupation

Favorite Hobbies

Do you feel stress? Explain

Are you currently under a physicians care?

Do you get angry often?

Are you happy? If not, why?

Have you been hypnotized before?

What were the results?

How long have you felt over stressed?

What other methods have you tried to reduce stress?

Does stress limit you and your activities? Explain:

Do you use caffeine? List: Do you use caffeine? List: YES NO

Is your stress job related? Explain:

Ar you taking any prescription medication for stress or depression? Please List:

Did you know hypnosis is 100% safe? Did you know hypnosis is 100% safe? YES NO

Is successful stress management a top priority? Is successful stress management a top priority? YES NO

If you have pressed the “Submit” button and nothing happened please scroll up the screen and find the Red Box of Required information.