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Life History Questionnaire
Full Name *
Email Address *
Phone Number *
Date of Birth *
Current Occupation
Relationship Status
Select one
Single
Married
Divorced
Widowed
In a Relationship
Describe your childhood
Significant life events (positive or challenging)
Current emotional or mental health concerns
Have you ever been diagnosed with a mental health condition?
Are you currently taking any medications?
Do you have any history of trauma?
What are your goals for hypnotherapy? *
Additional Notes
Submit Questionnaire
Thank you — your life history questionnaire has been submitted successfully.