Executive Level Application

Name *

First

Last

Name I like to be called *

Email *

Primary Contact Number *

Alternate / Work Phone *

Where you referred, if so by whom? *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth (MO/DY/YR) *

Gender *

Marital Status *

Occupation *

Current Income *

Have you ever been treated for an emotional problem? *

Yes No

If yes, please explain: *

Have you ever been hypnotized before? *

Yes No

If so, what for? *

Do you have any fears or phobias? *

Yes No

If yes, please explain: *

What do you want to accomplish through your work and use of The POWER Plan program, Coaching or Hypnotherapy? *

Any previous efforts to solve this problem? *

Yes No

If yes, please explain: *

If other, explain: *

By stating I Agree and signing below, I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for the treatment of any new or old illnesses.

Select Agreement Option *

I Agree I Disagree

Electronic Signature: Enter Full Name *

Client Intake Form