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Appointment & Intake Form 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!
You want to do therapy base on?pick all that apply!
How was your relation with your father when you were young?pick one!
How was your relation with your mother when you were young?pick one!

Please describe 1 (one) specific problem or disease that you want to solve in this hypnotherapy session 

Do you believe that you can recover from this problem/disease?pick one!
Do you believe that this problem/disease is due to heredity?pick one!
Has there ever been a doctor or someone you respect said that this problem/disease could not be cured or difficult to overcome?pick one!
Have you tried to solve this problem before?pick all that apply!
Have you done a hypnotherapy session before?pick one!
Based on your current understanding, hypnotic state is a state of?pick one!
Do you have concern about hypnosis and/or hypnotherapy?pick one!

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 relevant

Have you been in doctor’s treatment in the past?pick one!
Are you currently taking prescription medication?pick one!
Do you currently have any of the following?pick all that apply!
Are you currently under a doctor or psychiatrist treatment?pick one!
Please mark on these physical symptoms that you often havepick all that apply!

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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