Home[[[["field6","contains","Other"]],[["show_fields","field8"]],"and"]] 1 Step 1Appointment & Intake Form 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_libraryMarital Statuspick one!Marital StatusSingleMarriedWidow/WidowerRalationship Statuspick one!If married, how is your relationshipGoodAverageBadName of spousewcNumber of childrenpeopleName of childrenrecent_actorsAge of childrenrecent_actorsAddressyour home addresshomeQualification InformationHow did you know about us?pick all that apply!SeminarReferenceInternetYou want to do therapy base on?pick all that apply!Your own wishSomeone's wishOthersHow was your relation with your father when you were young?pick one!GoodAverageBadHow was your relation with your mother when you were young?pick one!GoodAverageBadPlease describe a specific issue / main problem that you want to solve in this hypnotherapy session Main Issue Descriptionmore details0 / Have you tried to solve this problem before?pick all that apply!HypnotherapyDoctorPsychologistPsychiatristCounsellingOthersDescribe how it was done and the resultsmore details0 / Have you done a hypnotherapy session before?pick one!YesNoBased on your current understanding, hypnotic state is a state of?pick one!SleepRelaxed/FocusedUnconsciousOthersDo you have concern about hypnosis and/or hypnotherapy?pick one!YesNoIf you have concern about hypnotherapy, can you briefly explainmore details0 / Related with the problem you want to solve in this therapy session, please rate the intensity of your feeling from 0 to 10, toward yourself, others, or to an event(s). 0 if you feel nothing and 10 if you intensely feel this emotion and it disturbs your life! Then explain briefly about the emotion. You just need to fill the emotions that you think are relevantAnger0 - 10 ; 0 is Normal and 10 Intense0010Anger - Briefly explainmore details0 / Disappointment0 - 10 ; 0 is Normal and 10 Intense0010Disappointment - Briefly explainmore details0 / Hurt0 - 10 ; 0 is Normal and 10 Intense0010Hurt - Briefly explainmore details0 / Revenge0 - 10 ; 0 is Normal and 10 Intense0010Revenge - Briefly explainmore details0 / Offended0 - 10 ; 0 is Normal and 10 Intense0010Offended - Briefly explainmore details0 / Hate0 - 10 ; 0 is Normal and 10 Intense0010Hate - Briefly explainmore details0 / Regret0 - 10 ; 0 is Normal and 10 Intense0010Regret - Briefly explainmore details0 / Frustrated0 - 10 ; 0 is Normal and 10 Intense0010Frustrated - Briefly explainmore details0 / Fear/Afraid0 - 10 ; 0 is Normal and 10 Intense0010Fear/Afraid - Briefly explainmore details0 / Nervous/Anxious0 - 10 ; 0 is Normal and 10 Intense0010Nervous/Anxious - Briefly explainmore details0 / Shame0 - 10 ; 0 is Normal and 10 Intense0010Shame - Briefly explainmore details0 / Lonely0 - 10 ; 0 is Normal and 10 Intense0010Lonely - Briefly explainmore details0 / Sad0 - 10 ; 0 is Normal and 10 Intense0010Sad - Briefly explainmore details0 / Incapable0 - 10 ; 0 is Normal and 10 Intense0010Incapable - Briefly explainmore details0 / Rejected0 - 10 ; 0 is Normal and 10 Intense0010Rejected - Briefly explainmore details0 / Unworthy0 - 10 ; 0 is Normal and 10 Intense0010Unworthy - Briefly explainmore details0 / Unwanted0 - 10 ; 0 is Normal and 10 Intense0010Unwanted - Briefly explainmore details0 / Have you been in doctor’s treatment in the past?pick one!YesNoAre you currently taking precription medication?pick one!YesNoDo you currently have any of the following?pick all that apply!Heart problemAsthmaPregnancyStrokeDiabetesCerebral PalsyHypertensionHypotensionEpilepsyNoneAre you currently under a doctor or psychiatrist treatment?pick one!YesNoPlease mark on these physical symptoms that you often havepick all that apply!SinusitisMigraineUlcerNeck painFrozen shoulderPain upper backPain lower backMenstrual crampIrregular periodJoint crampConstipationGastricSweaty palmCold feetPain on legsSwollen feetHow do you know when you have solved your main issue/problem? How would you feel?more details0 / What positive change that will happen in your life when you solve your main issue/problem ?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