HypnoBody Release application form

Your Name

First

Last

Your Email

Phone Number

Birth date

1. What pattern feels most difficult for you to change right now?

2. How does this pattern show up in your body or nervous system?

Examples: tension, shutdown, worry, hypervigilance, numbness, procrastination.

3. When did you first notice this pattern in your life?

You do not need to share details, just timing.

4. What have you already tried to resolve this pattern?

5. What would be different in your life if this pattern no longer ran your decisions?

6. HypnoBody Release℠ is a structured, body-led process, not talk therapy or crisis support. Are you willing to engage in a contained, multi-month process?

Yes
No

7. Are you currently under the care of a licensed mental health professional?

Yes (if yes, a referral from a clinician is needed.)
No

medical that to

8. On a scale of 1–10, how willing are you to take responsibility for your inner work?

Selected Value: 0

1=passive, 10= fully responsible.

9. Is there anything you feel would prevent you from completing a four-month commitment?

10. Why do you feel HypnoBody Release℠ is the right approach for you at this point in your life?

11. How urgent does this change feel for you right now?

I’m curious but not in a rush
I know something needs to change, but timing feels unclear
I feel increasingly constrained by this pattern
I’m no longer willing to stay this way

12. If nothing changes over the next 6–12 months, what do you expect will stay the same in your life?

13. If this pattern were no longer active, how would your day-to-day life be different?

14. What does “commitment” mean to you in a multi-month personal process?

15. Have you been hypnotized before?

Yes
No
Unsure

15b. If yes, can you share about that experience, thank you.

16. Can you please tell me, are you a visual, auditory, or feeling person?

We all experience life through our senses, please let me know what are the most important in order for you.

17. Do you believe in any of the following?

Please check all that apply, and if so, please proceed to answer the following questions.

17a. Birth Time

Please enter a.m or p.m is not using 24 hr format.

17b. Birth Place

City, Country

17c. Religious or Spiritual belief

18. HypnoBody Release℠ requires both time and financial investment. How do you generally relate to investing in yourself?

I avoid investing in myself
I invest when I feel desperate
I invest carefully but consistently
I see self-investment as essential

Choose the statement that is closest to you truth.

19. Do you believe you are worthy of investing in resolving this pattern?

Yes
No
Unsure

20. If accepted, are you prepared to prioritize this work over avoidance, distraction, or postponement?

Yes
I’m willing to explore what that would require
No

21. Is there anything you’re hoping this process will “do for you” without your active participation?

Remember I am a hypnocoach but I cannot do the work for you. Your participation and commitment to the show up for yourself on this journey is essential.

22. Do you have any medical conditions that I need to know about for your safety?

Please list conditions such as hypoglycemia, low blood pressure, epilepsy, etc as I am committed to your safety during our sessions.

23. I have answered these questions to the best of my abilty

Thank you. If we are a good match, you will be hearing from me shortly to schedule a clarity call. If not, I have something for you on the way.

HypnoBody Release Application form