Intake Child Eng - Yoshiko Sinaga CHt, CT

Appointment & Intake Form | Child / Teen | English

YoshikoSinaga.com

Please answer the form as honest as you can to make the session productive for you.

General Information

Place of BirthPlace of Birth

Religionyour religion

Name and Age of Siblings

Addressyour home address

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 details

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How long have your child had this problem?more details

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Is your child currently under doctor/psychiatrist/counsellor treatment?pick one!

YesNo

If Yes, Where?more details

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Names of Doctor/Psychiatrist/Counsellormore details

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To be filled by the Child / Teen

Please explain briefly your choices of whats bothering youmore details

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What do you think will happen when you solve this problem?more details

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To be filled by the Parent

What is the main language of the child?more details

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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 details

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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 details

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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 details

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What is your expectation from the child as the outcome of this hypnotherapy session?more details

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In your opinion, what benefit will you get when you solve your child's problem?more details

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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 details

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Session Appointment Details

The fee for each session is Rp2.000.000, the session is approximately 2 -3 hours. 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 appointment