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Appointment & Intake Form | Child / Teen | English


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

General Information

Qualification Information

How did you know about us?pick all that apply!
Does your child want to do therapy base on?pick one!
What is your child current level in school?pick one!
How is the child's relationship with Father?pick one!
How is the child's relationship with Mother?pick one!
How is the child's relation with siblings?pick one!

Please describe a specific issue / main problem that you or your child want to solve in this hypnotherapy session 

Is your child currently under doctor/psychiatrist/counsellor treatment?pick one!
To be filled by the Child / Teen

What is your favorite place to be?pick all that apply!
What is your hobby or favorite thing to do?pick all that apply!
What is bothering you at the moment?pick all that apply!
To be filled by the Parent

Who is the main care taker of the child?pick one!
Was there a specific problem during pregnancy or delivery?pick one!
Was there any negative experience or trauma experienced by the child when he/she was young?pick one!
Have you done any hypnotherapy session before?pick one!
In your opinion, hypnosis/hypnotherapy is a state of...pick one!
Do you have any concern about hypnosis/hypnotherapy?pick one!

Session Appointment Details

The fee for each session is Rp2.000.000, the session is approximately 2 -3 hours. Please  inform the therapist by WhatsApp to 08118401037 to make appointment. Thank you.

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