- LifeStyle by Choice -                              
                                                          (ALL INFORMATION IS CONFIDENTIAL)

NAME ______________________________________________________           DATE ________________________

STREET ADDRESS ___________________________________________  STATE ______ ZIP __________________

HOME PHONE _____ ______________________           CELL PHONE ______ ______________________________

(I give you permission to be contacted via e-mail: YES _____    NO _____,          home phone: YES _____  NO _____       
cell phone: YES _____ NO _____ )

BIRTHDATE ________________      MALE _____     FEMALE _____

EMERGENCY CONTACT _____________________________________         PHONE _____ ____________________

Have you been hypnotized before? ________  When ___________   Results __________________________________

What is the reason(s) for you wanting hypnosis?

Have you used other types of treatment for the above issue? YES ______      NO _____

If you have please indicate the type of treatment and its effectiveness:

Are you experiencing any mental health issues at this time?  YES _____    NO _____
      Please explain:

Are you taking medication for the above?  YES _____  NO _____                              
      What Type(s):

Have you ever been treated for any of the following? CHECK BOX BELOW.     

Arthritis _____      Diabetes _____         High Blood Pressure _____                Heart trouble_____             

Seizures/Epilepsy _____    Obesity _____  Anxiety _____  Stress _____ Depression _____      

Broken Bones _____    Other _______________________________________________________________

Do you feel that you can gain control of the issue that you are here for today?    YES _____      NO _____


I am willing to be guided through mental and physical relaxation techniques, visual imagery, hypnosis, and or
Neuro-linguistic Programming (NLP). I understand that there are no guarantees for changing human behavior throught
this process. I also understand that the services I purchase from LifeStyle by Choice, LLC are not to be used as a
substitute or replacement for professional medical or mental health advice or care.   

SIGNATURE ____________________________________________     DATE ____________

LifeStyle by Choice, LLC
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Name: ___________________________________                        Date: ____________

Please put a check mark next to any conditions, emotions, or feeling which describe you or have interfered with your daily routine.
This is confidential information

Nail biting                                      Workaholic habits                                 Insomnia     

Is there a certain time that you wake up at night __________________________

Too much sleep       How many hours do you sleep each day _________________

How many hours are you in bed each day __________________   Restless sleep                               Irritability 
Depression             > Is there a time day you usually feel depressed __________________________________________
Anxiety                                        Fatigue                                  Restlessness  
Confusion                       > Explain ______________________________________________________________________   
Desire to drink                      >Describe what type of substance you drink: _____________________________________   
Craving of sugar products

Craving of __________________________________________________________________________________________                       
When I crave, it is in the morning _____, afternoon _____,  early evening _____, late at night _____  
I got _____ or get _____  along with my father all the time _____, sometimes _____, never _____                            

                                                                   LifeStyle by Choice, LLC
                                                                             Page 3

I got _____  or get _____ along with my mother all the time _____, sometimes _____, never _____                         .

I was called names during the age’s of __________________________,  or I was never called names________________.

Either my father _____or mother _____used alcohol or other drugs in excess.

       Explain the drugs they used

Please add any other conditions, feelings or emotions which you experience: