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This is a secure form. Please fill out giving as much detail as possible or email me at info@muse-hypnosis.com if a privately sent form is preferred
What would you like to achieve with this hypnosis? *
Regarding the problem/theme, what is your present state? Describe in as much detail as possible. *
And what is your target state? Describe in as much detail as possible. *
Describe what will happen once you have fixed the problem: *
Describe what your life will look and feel like: *
What will change in your life? *
What will happen if you don’t fix this? *
What does this problem presently permit you to do? *
What does the problem prevent you from doing? *
What does the problem permit you to not do? *
In the recording, would you like your name mentioned? If so, what may I call you? *
Which do you consider your best learning style: *
Have you been under hypnosis before? *
Briefly Describe
What modality/therapy, if any, in the past has helped this problem? *
What modality/therapy has not helped? *
Any further info?