Life Map Hypnosis with Tania Smith - Rainbow Lovina Healing Arts, LLC Life Map Hypnosis with Tania Smith - Rainbow Lovina Healing Arts, LLC Name * Name First First Last Last Address * Date of Birth * Occupation * Email * Phone Marital Status * Name of Spouse (if applicable) Name/s & Age/s of Child/Children * List your three (3) colors in order of preference * List your three (3) favorite places in order of preference * On vacation which do you prefer? * Relaxation Excitement List any fears or phobias * Do you suffer from any compulsive tendencies? * Yes No Maybe List any current health problems * List any medications you are currently taking * Please list your three (3) most important lifetime goals * List your three (3) favorite past-times/hobbies * Do you enjoy your current occupation? * Yes No Maybe List things that you like to do but you wish you could do better * If you could be, do, have or become anything what would you wish for? * Why are you seeking hypnotherapy? * Are you currently suffering from any of the following? * Nervousness Inability to relax Sleeplessness Sexual Dsyfunction Compulsive Tendencies Nail Biting Teeth Grinding Nightmares Poor Health Poor Memory Cigarette Smoking Alcohol Abuse New Option Drug Abuse Co-dependency Compulsive Overeating Serious Eating Disorder Marital Problems Recent Divorce War Trauma Inability to focus attention Current Illness Death of a loved one Childhood Trauma Lack of energy Poor self-esteem Abusive Home Situation Lack of Success Sexual Abuse Other Do you follow or observe any religious or meditative practices? If so please describe: * Do you believe you have lived in a past life? * Yes No Maybe List any other conditions that are occurring in your life that are affecting you in any way? * Are there any other needs or concerns that you have * If you are human, leave this field blank. Submit Δ
