Behavior Change Intake

Thank you for choosing to begin this process. This form is designed to help us understand your goals, challenges, and patterns so we can tailor a hypnotherapy session to your needs. Whether you’re working to break a habit, quit smoking, reduce emotional eating, build confidence, or shift unwanted behaviors, your responses will help ensure your session is focused and effective.

What to Expect:

This form takes about 15–25 minutes to complete. You’ll be asked about your goals, patterns, and past efforts toward change. Your responses are saved automatically in your browser as you go, so you can pause and return later if needed (as long as you use the same device).

Repetition

Some questions may feel repetitive—this is intentional. Revisiting topics helps you open up, clarify details, and go deeper, so we can focus your responses and tailor your hypnosis session more precisely.

Privacy Reminder:

All information you provide is confidential, securely stored, and used solely to support and personalize your hypnotherapy session. It will never be shared without your consent.