Home[[[["field6","contains","Other"]],[["show_fields","field8"]],"and"]] 1 Step 1Appointment & Intake Form | Child / Teen | EnglishYoshikoSinaga.comPlease answer the form as honest as you can to make the session productive for you.General InformationFirst Nameassignment_indLast NameassignmentNicknameassignmentPlace of BirthPlace of BirthplaceDate of Birthdate_rangeGenderpick one!GenderMaleFemaleOtherEmaila valid emailemailPhone NumberphoneReligionyour religionlocal_libraryName of FatherpersonName of Motherperm_identityName and Age of Siblingssupervisor_accountAddressyour home addresshomeQualification InformationHow did you know about us?pick all that apply!SeminarReferenceInternetDoes your child want to do therapy base on?pick one!His or Her own wishYour wishWhat is your child current level in school?pick one!KindergartenPrimary SchoolMiddle SchoolHigh SchoolHow is the child's relationship with Father?pick one!GoodAverageBadHow is the child's relationship with Mother?pick one!GoodAverageBadHow is the child's relation with siblings?pick one!GoodAverageBadPlease 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!YesNoIf Yes, Where?more details0 / Names of Doctor/Psychiatrist/Counsellormore details0 / To be filled by the Child / TeenWhat is your favorite place to be?pick all that apply!GardenBeach Mountain Lake School Home Playground OtherWhat 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 OthersWhat 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 OthersPlease 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 ParentWho is the main care taker of the child?pick one!Mother FatherGrandparent Nanny OthersWhat is the main language of the child?more details0 / Was there a specific problem during pregnancy or delivery?pick one!YesNoIf 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!YesNoIf 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!YesNoIn your opinion, hypnosis/hypnotherapy is a state of...pick one!SleepUnconsciousRelax and focused mindDo you have any concern about hypnosis/hypnotherapy?pick one!YesNoIf 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 DetailsPlease note schedule appointment are subject to the availability of the therapist. The therapist will confirm the schedule via a phone call or WA chat.Session Dateof appointmentdate_rangeSession Timeof appointment09150030access_timeSubmit Formkeyboard_arrow_leftPreviousNextkeyboard_arrow_right