Hypnotherapy Intake Process Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *How did you hear about Melissa Kim Corter?Google SearchSocial MediaReferralRelationship StatusMarriedSingleDivorcedWidowedAre you currently suffering from any of the following? (Please check all that apply) *Nervousness or anxietyStressDepressionEmotional distress (sadness, grief, etc.)Compulsive tendencies (smoking, overeating, overindulging in alcohol, nail biting, teeth grinding)Memory concernsInability to focusPhysical Concerns (illness or disease)Sleep disturbances (nightmares, sleeplessness, insomnia, trouble resting)Fatigue/low energyLacking of hope/ Not feeling inspiredSuicidal or Self harmIrrational fears (spiders, heights, bridges, etc.)Please elaborate on medical issues, emotional distress, compulsive tendencies, physical concerns, irrational fears, or concerns from above (if any)Please list medications if any:On a scale of 0-10 please rate your level of self esteem (o none at all or 10 feel really good about self)List any fears, concerns or worries in your mindI am happiest when _____________Please list your three most important lifetime goals:What do you do for work/career and do you enjoy it?If you could be, do, have or become anything, what would you wish for?Why are you seeking hypnotherapy?What behaviors get in the way of your happiness?If I were not afraid to be myself I would:One of the ways I could help myself but don’t is....What would you like to start doing?What would you like to stop doing?What would you like to do more of?What would you like to do less of?Please list any additional needs or concerns:RELEASE STATEMENT I hereby authorize Melissa Kim Corter to create an MP3 Hypnosis track for the purposes outlined in this intake form and for the future purposes I may request. I understand that the success of my hypnosis depends greatly on my own ability and desire to affect change in myself. I understand that the results of my sessions depend greatly on my own serious participation that Melissa Kim Corter cannot offer any guarantee of the success of my treatment. I am aware, however, Melissa Kim Corter will do everything in her power to ensure my success. I also understand that I have other choices from which to see assistance regarding my specific concerns, and I have chosen hypnotherapy at this time. *FirstLastNameSubmit
