Home [[[["field6","contains","Other"]],[["show_fields","field8"]],"and"]] 1 Step 1 Appointment & Intake Form EnglishYoshikoSinaga.com​Please answer the form as honest as you can to make the session productive for you. General Information First Nameassignment_ind Last Nameassignment Nicknameassignment Place of BirthPlace of Birthplace Date of Birthdate_range Genderpick one!GenderMaleFemaleOther Emaila valid emailemail Phone Numberphone Religionyour religionlocal_library Marital Statuspick one!Marital StatusSingleMarriedWidow/Widower Ralationship Statuspick one!If married, how is your relationshipGoodAverageBad Name of spousewc Number of childrenpeople Name of childrenrecent_actors Age of childrenrecent_actors Addressyour home addresshome Qualification Information How did you know about us?pick all that apply!SeminarReferenceInternet You want to do therapy base on?pick all that apply!My own wishSomeone's wishOthers How was your relation with your father when you were young?pick one!GoodAverageBad How was your relation with your mother when you were young?pick one!GoodAverageBad Please describe 1 (one) specific problem or disease that you want to solve in this hypnotherapy session Problem / Disease Descriptionmore details0 / Do you believe that you can recover from this problem/disease?pick one!YesNo Do you believe that this problem/disease is due to heredity?pick one!YesNo 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!YesNo Have you tried to solve this problem before?pick all that apply!HypnotherapyDoctorPsychologistPsychiatristCounsellingOthers Describe how it was done and the resultsmore details0 / Have you done a hypnotherapy session before?pick one!YesNo Based on your current understanding, hypnotic state is a state of?pick one!SleepRelaxed/FocusedUnconsciousOthers Do you have concern about hypnosis and/or hypnotherapy?pick one!YesNo If 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 relevant Anger0 - 10 ; 0 is Normal and 10 Intense0010 Anger - Briefly explainmore details0 / Disappointment0 - 10 ; 0 is Normal and 10 Intense0010 Disappointment - Briefly explainmore details0 / Hurt0 - 10 ; 0 is Normal and 10 Intense0010 Hurt - Briefly explainmore details0 / Revenge0 - 10 ; 0 is Normal and 10 Intense0010 Revenge - Briefly explainmore details0 / Offended0 - 10 ; 0 is Normal and 10 Intense0010 Offended - Briefly explainmore details0 / Hate0 - 10 ; 0 is Normal and 10 Intense0010 Hate - Briefly explainmore details0 / Regret0 - 10 ; 0 is Normal and 10 Intense0010 Regret - Briefly explainmore details0 / Frustrated0 - 10 ; 0 is Normal and 10 Intense0010 Frustrated - Briefly explainmore details0 / Fear/Afraid0 - 10 ; 0 is Normal and 10 Intense0010 Fear/Afraid - Briefly explainmore details0 / Nervous/Anxious0 - 10 ; 0 is Normal and 10 Intense0010 Nervous/Anxious - Briefly explainmore details0 / Shame0 - 10 ; 0 is Normal and 10 Intense0010 Shame - Briefly explainmore details0 / Lonely0 - 10 ; 0 is Normal and 10 Intense0010 Lonely - Briefly explainmore details0 / Sad0 - 10 ; 0 is Normal and 10 Intense0010 Sad - Briefly explainmore details0 / Incapable0 - 10 ; 0 is Normal and 10 Intense0010 Incapable - Briefly explainmore details0 / Rejected0 - 10 ; 0 is Normal and 10 Intense0010 Rejected - Briefly explainmore details0 / Unworthy0 - 10 ; 0 is Normal and 10 Intense0010 Unworthy - Briefly explainmore details0 / Unwanted0 - 10 ; 0 is Normal and 10 Intense0010 Unwanted - Briefly explainmore details0 / Have you been in doctor’s treatment in the past?pick one!YesNo Are you currently taking prescription medication?pick one!YesNo Do you currently have any of the following?pick all that apply!Heart problemAsthmaPregnancyStrokeDiabetesCerebral PalsyHypertensionHypotensionEpilepsyNone Are you currently under a doctor or psychiatrist treatment?pick one!YesNo Please mark on these physical symptoms that you often havepick all that apply!SinusitisMigraineUlcerNeck painFrozen shoulderPain upper backPain lower backMenstrual crampIrregular periodMuscle crampConstipationGastricSweaty/cold palmCold feetPain on legsSwollen feet How 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 DetailsThe fee for each session is Rp1.500.000. 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 appointmentdate_range Submit Form keyboard_arrow_leftPrevious Nextkeyboard_arrow_right