Free Consultations

To schedule your consultation, please complete an intake form and a client consent form. You will be invited to schedule your appointment online.

I am currently offering appointments in the office at 655 University Avenue, Suite 202 or via phone or Zoom.

AMARA hypnotherapy

Confidential Intake Form

* Indicates required field

Name *

First

Last

How did you hear about AMARA Hypnotherapy? *

Email *

Phone *

Birthdate *

What are your goals for hypnotherapy? What are the changes you would like to create? What is your vision of success? *

Do you prefer to meet in the office or by phone? *

Have you ever experienced hypnotherapy? *

Mailing Address *

City, State, ZIP *

Country *

Occupation *

Employer *

Are you currently under the care of a doctor or mental health professional? *

Yes No

Please list any medical conditions that you have experienced in the past two years. *

Please list any medications, vitamins, or supplements that you take on a regular basis. *

Please describe the places and activities that you find most relaxing. *

Thank you. Please continue to schedule your free consultation.

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