First Name:
Last Name:
Address:
City:
State:
Zip Code:
E-Mail Address:
Phone Number:
List any phobia that you may have
Reason(s) why you want a Hypnotherapy recording
1. Do you ever become so involved in a TV Program, Movie or play that you lose awareness of
where you are?
Seldom
Sometimes
Often
2. In the midst of a conversation, has the person with whom you are speaking asked, "are you with
us"?
Seldom
Sometimes
Often
3. When reading or hearing about someone else's experience, do you get deeply involved?
Seldom
Sometimes
Often
4. Have you ever waited at a red light and suddenly realized that the person in the car behind you
has been honking his horn because the light has changed?
Seldom
Sometimes
Often
5. Have you ever been able to recall an experience so vividly that you almost feel that you were
actually reliving it?
Seldom
Sometimes
Often
6. Have you ever been deeply moved by an eloquent or poetic speaker or singer?
Seldom
Sometimes
Often
7. Have you ever arrived at home with an object that a salesperson convinced you was perfectly
suited for you to only realize that you really did not want it?
Seldom
Sometimes
Often
8. Did you ever glance at the clock or watch while reading a book to find that and hour or so later
than you had thought it was?
Seldom
Sometimes
Often
9. Do people complain that they have told you important things which you cannot remember?
Seldom
Sometimes
Often
10. Have you ever been physically hurt (a cut or a bruise) and only realized it later when you
actually saw it?
Seldom
Sometimes
Often
Any additional comments
Preferred format
Tape
CD
