Spiritual Hypnosis Intake Form

Please take a moment to review and complete the information below at least 24 hours before your scheduled appointment.

🌿 Welcome to Spiritual Hypnotherapy

Before our session together, I invite you to fill out this Spiritual Hypnotherapy Intake Form. This is a confidential space to share whatever feels true to you at this time.

Everything you choose to share helps me better understand your unique journey, intentions, and needs — but nothing is mandatory. Write a lot, or just a little. And, if a question doesn’t feel right to answer, please just skip it.

One exception: If there are any medical conditions, prescription medications, or mental health diagnoses I should be aware of, I kindly ask that you include those. This is important for your safety and for me to support you ethically and responsibly.

With gratitude,
✨ Mari-Claire

Name

First Name

Last Name

Phone

(###)

###

####

Does the number above work for WhatsApp?

Yes

Have you ever experienced in-person hypnotherapy before?

Yes

Recorded Only

Do you believe you are easily hypnotizable?

Yes

Curious to find out.

Have you explored any other energy medicine or healing modalities? (Examples: Reiki, acupuncture, breathwork, plant medicine, sound healing, somatic therapy, etc. Please share your experiences if you feel called.)

What would feel meaningful or healing for you in our session together? Are you bringing in specific intentions to be addressed? (Feel free to write about what you're hoping to explore, release, connect with, or experience.)

How would you describe your current spiritual beliefs or practices? (If any. Feel free to name specific traditions or paths, or simply your personal connection with the sacred.)

Are there any spiritual blocks or barriers you're aware of? (Examples: fear, trauma, doubt, past teachings, ancestral beliefs, etc.)

What does your self-image look and feel like right now? (This can include emotional, physical, or spiritual perceptions of self.)

TextWhat does "spiritual language" mean to you? (Examples: "I speak in metaphors," "I connect with nature," "I resonate with angels," "I don’t use spiritual language at all." There’s no wrong answer.)

What do you understand or believe about the subconscious mind? (This is not a test — just curious how you relate to the unseen parts of your mind or being.)

Is there anything I should know about you, your history, or what you're bringing into the space? (This could include trauma, triggers, sensitivities, or anything else you want held with care.)

Physical and mental health. What should I be aware of before our session? Including: prescription medications, mental health diagnoses, or other conditions that could impact your experience and safety during hypnosis.

Spiritual Hypnosis Intake Form

🌿 Welcome to Spiritual Hypnotherapy

Selva Segrada

Transformational Coaching