(309) 518-9333
marian@quadcitieshypnosis.com
Intake Form PSP Session
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Instructions
(optional)
Welcome to my short intake form! All answers are confidential.
Name
Email Address
Phone Number
Are you over 18?
Yes
No
If you have any physical or mental health diagnoses, are you under the care of someone with the correct license to treat that condition?
Yes I have licensed healthcare for my diagnosis
No I don't have licensed healthcare for my diagnosis
I don't have any diagnoses
What are we working on?
Describe the change you seek to create
Describe how you'll be feeling on the other side of this change
What, if any, are your spiritual beliefs?
What, if any, is your experience with the PSP? Do you have any certain inductions or approaches that you know work well?
How many sessions are you booking?
1 session ($200)
2 sessions ($400)
3 sessions ($500)
6 sessions ($1000)
I'll send you a PayPal invoice
Scheduling
(optional)
Tuesdays at 10am CST
Tuesdays at 12pm CST
Tuesdays at 2pm CST
Tuesdays at 4pm CST
Thursdays at 10am CST
Thursdays at 12pm CST
Thursdays at 2pm CST
Thursdays at 4pm CST
Thursdays at 6pm CST
Fridays at 10am CST
Saturdays at 10am CST
Saturdays at 12pm CST
If we haven't already scheduled, select up to 3 and I'll get back to you to confirm one.
Confidentiality, Self-Responsibility, Cancellation Policy
I agree to the terms and conditions
Signature
I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law