Home 1 Step 1 Appointment & Intake Form | Child / Teen | EnglishYoshikoSinaga.com​Please answer the form as honest as you can to make the session productive for you. General Information First Nameassignment_ind Last Nameassignment Nicknameassignment Place of BirthPlace of Birthplace Date of Birthdate_range Genderpick one!GenderMaleFemaleOther Emaila valid emailemail Phone Numberphone Religionyour religionlocal_library Name of Fatherperson Name of Motherperm_identity Name and Age of Siblingssupervisor_account Addressyour home addresshome Qualification Information How did you know about us?pick all that apply!SeminarReferenceInternet Does your child want to do therapy base on?pick one!His or Her own wishYour wish What is your child current level in school?pick one!KindergartenPrimary SchoolMiddle SchoolHigh School How is the child's relationship with Father?pick one!GoodAverageBad How is the child's relationship with Mother?pick one!GoodAverageBad How is the child's relation with siblings?pick one!GoodAverageBad Please describe a specific issue / main problem that you or your child want to solve in this hypnotherapy session Main Issue Descriptionmore details0 / How long have your child had this problem?more details0 / Is your child currently under doctor/psychiatrist/counsellor treatment?pick one!YesNo If Yes, Where?more details0 / Names of Doctor/Psychiatrist/Counsellormore details0 / To be filled by the Child / Teen What is your favorite place to be?pick all that apply!GardenBeach Mountain Lake School Home Playground Other What is your hobby or favorite thing to do?pick all that apply!Play with phone / gadgetPlay games Watching TV Reading Drawing Listening to music Play with friends Play with pets Sports Play musical instrument Dancing Others What is bothering you at the moment?pick all that apply!Anger Disappointment Anxiety/Nervous Fear/afraid Sadness Hurt Bored Lonely Can't focus Pain Bad habit Addiction Low grades Others Please explain briefly your choices of whats bothering youmore details0 / What do you think will happen when you solve this problem?more details0 / To be filled by the Parent Who is the main care taker of the child?pick one!Mother FatherGrandparent Nanny Others What is the main language of the child?more details0 / Was there a specific problem during pregnancy or delivery?pick one!YesNo If there was a specific problem during pregnancy or delivery, can you explain briefly?more details0 / Was there any negative experience or trauma experienced by the child when he/she was young?pick one!YesNo If there was a specific negative experience or trauma experience by child, can you explain briefly?more details0 / Have you done any hypnotherapy session before?pick one!YesNo In your opinion, hypnosis/hypnotherapy is a state of...pick one!SleepUnconsciousRelax and focused mind Do you have any concern about hypnosis/hypnotherapy?pick one!YesNo If you have any concern about hypnosis/hypnotherapy? If yes please explain brieflymore details0 / What is your expectation from the child as the outcome of this hypnotherapy session?more details0 / In your opinion, what benefit will you get when you solve your child's problem?more details0 / What kind of behaviour or mindset that you have as parent that you think is or may prevent you from achieving what you want from your child?more details0 / Session Appointment DetailsThe fee for each session is Rp1.500.000. Please select the available date and time to schedule the appointment and inform the therapist by WhatsApp to 08118401037 to get confirmation on the schedule. Session Time & Datemake an appointmentdate_range Submit Form keyboard_arrow_leftPrevious Nextkeyboard_arrow_right