Questionnaire
...for Custom Recording and Telephonic Session

Please complete the following questions to the best of your ability - this helps me create a self-hypnosis recording specifically designed for you, in your name and specific to your issues. If there are scenes or words that you may not be comfortable with or may have difficulty imagining or dislike, please specify those as well.

• First Name:
• Last Name:
• Complete Address
• Best Tel # to reach you.
• Your Age
• Birth date
• E-Mail:
• Occupation/Current work:
• General Health?
  Please note any medication or other preparation you are on at this time and daily dosage.

Client

To help us make the most of time available to you, please complete each of the items below. If an item does not apply to you, just write: N/A Your thorough and honest responses will help us provide more efficient and effective service to you.

1. How did you happen to hear about us?
 
2. Have you ever been in counseling or psychotherapy?
 If so, how long and with what results?
 
4. How long have you been in this situation? What made you decide to change the situation Now?
 
5. Circle how this bothers you at home or at work.
a) Decision Making b) Exhausted c) Decreased Productivity d) Poor Attitude

6. Have you ever been in hypnosis? If so, under what conditions?

Please be as detailed as possible - this will help Liza become more acquainted with your thoughts and concerns in creating the best possible suggestions so that your subconscious to accept.
 
7. What is the main goal that you would like hypnosis to help you with (i.e., weight loss, smoking cessation, anxiety, sleeplessness)?

8. What are your smaller goals (“sub-goals”) that you want to accomplish to help you with your main goal (i.e., quitting junk food for weight loss, motivation to exercise, handling stress better or overcoming post pregnancy depression)?

9. How and when did your main problem/issue began and why? How long have you been in this situation?

10. What is the general history of your problem from the beginning until now (including times of recovery and relapse)?

11. What are the main difficulties/symptoms that this problem has caused in your life?

12. What rewards/payoffs/reinforcements has your problem provided for you that has made it difficult to give up/stop doing? (Think hard about this and be honest with yourself).

13. What is your family history with your problem (parents, siblings, partner in life and/or extended family with the same issue)?

14. Why do you want to change now and what are you willing to do differently now to help you finally succeed (different than with your previous efforts)?

15. Why do you want to change now and what are you willing to do differently now to help you finally succeed (different than with your previous efforts)?

16. Why do you want to change now and what are you willing to do differently now to help you finally succeed (different than with your previous efforts)?

17. What is your previous experience with and opinion about hypnosis?

18. How strongly would you rate yourself from 1 (very weak) -10 (very strong) with how well you feel you can engage in the following:

a) Being able to relax when you choose to

b) Visualizing scenes or situations in your mind

c) Recalling recent memories from the past

d) Recalling distant memories from the past

e) Telling yourself to do certain things in your mind

19. Do you have any specific fears or phobias (just to make sure it is not mentioned during the recording)

This section may or may not be applicable to your issues. Your family’s history may also be of value. Please check any of the following that may apply to your blood relatives.

• If you smoke or use tobacco, how much do you consume on an easy day?______ On a difficult day?______
 
• If you use alcohol, what form and how much do you consume on an easy day?______ On a difficult day?______
 
• If you use mood-altering drugs (Valium, pot, diet pills, etc.), how much do you consume on an easy day?______ On a difficult day?______
 
• If you use food to relieve tension, how much do you consume on an easy day? _______ On a difficult day?______
 
• How many easy days do you usually have per week?______ How many difficult days?______

Note any conditions requiring your hospitalization or outpatient treatment over the last five years. Include approximate dates.

Currently in treatment for: _______________________________________

Doctor’s name and location. ______________________________________

Self Inquiry

Rate the following statements by checking one of the boxes for each, ranging from Almost Never to Almost Always as it applies to you. When you have finished, you may score the items yourself if you wish. There are no trick questions, so just give your honest response to each item.

Please fill in the blank:

• My best quality is:
• My worst quality is:
• Something I wish I could change about my life:
• Two things for which I am thankful:
• The emotion I tend to hide the most is:
• Something that makes me happy:
• When I am sad I need:
• My greatest fear is: