This form is designed to help us understand your experience with pain—physically, emotionally, and functionally—so we can tailor a hypnotherapy session that supports your comfort, safety, and well-being.
Privacy Reminder:
Your responses are confidential, securely stored, and used only to prepare your hypnotherapy session. We do not share your information without your consent.
Important!
Hypnosis can be very effective at reducing pain—sometimes almost completely. Because pain is a vital warning signal, turning it off without proper medical evaluation could delay needed care. Hypnosis is a complementary wellness tool and not a substitute for medical diagnosis or treatment. If your pain is new, worsening, unexplained, or not yet assessed, please see a healthcare professional first. If your pain has been medically diagnosed, we may request written permission from your healthcare provider before proceeding, as we will not use hypnosis to mask symptoms that require medical attention.
What to Expect:
The form takes approximately 15–25 minutes to complete. Your answers are automatically saved in your browser as you go, so you can take breaks and return to the form on the same device without losing your progress.
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.
What to Fill Out
This form applies to chronic, post-surgical, and acute pain. Please complete the sections that are relevant to you. The depth and quality of the information you provide will directly improve the effectiveness of your hypnosis session, because we draw on your own subconscious insights to help shift pain perception and support healing.
