Burlington Hypnosis Intake Form

NOTE: All information is confidential except that which Paul is legally obligated to report, such as the threat to injure yourself or others.
The more detail you offer about your goals the more help Paul can be.

Have you encountered previous experience with hypnosis, meditation, guided imagery or progressive relaxation?

Howdid you hear about Burlington Hypnosis?

Have you watched the introduction to hypnosis video?

Are you under psychological care?

Are you experiencing any of the following? Depression, Anger, Anxiety, Hopelessness, Crying, Fatigue, Nightmares, Phobia, Worry, Self-injury, Insomnia, PTSD -- Please rate all that apply below:

13 + 7 =