MARILYN OCEAN
VISION INTO SUCCESS
Confidential questionnaire

Please fill out this questionnaire prior to your session. Giving it serious thought will make our time together both successful and productive.

Name:

Date:

Address :
Cell Phone:
Email :
Occupation :
Work Phone:
Birth date : Sex : Marital Status :
Education : Degree :
Major : Favorite Hobby
Are you under the care of a doctor? : If yes, explain :
Do you exercise? : How often? : What Type? :
Do you enjoy your work? : Do you feel stress from your job? :
If yes please explain :
Do you now have a substance abuse problem? : Ever?
What is your Primary Goal? :
What do you expect from Hypnosis? :
Have you ever been hypnotized before? : By whom if yes? :
Results :
How did you hear about me? :

If referred by a client please tell me who so I can send them a thank you note.

MARILYN OCEAN
VISION INTO SUCCESS
Confidential questionnaire

Name :
What causes you stress? :
What do you do to relax? :
Are you having difficulty sleeping? :

Please rate each of the following feeling ans emotions on a scale of 1-10 where 1 equals “I almost never experience this feeling” and (10) equals “I constantly experience this feeling” Please be honest and complete with your responses.

Fear Anger Guilt Depression Sadness Self- Loathing Being wronged by others Hatred Stress Doubt Blaming Satisfaction Joy Harmony Acceptance Gratitide Happiness Peace of mind Humility



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