INTAKE FORM - Online Coaching One-on-One

Please fill out and submit this form to requests a one-on-one coaching program with me.

First Name *

Last Name *

Phone *

Email *

Address

Street Address

City *

State *

Country *

Zip code/Postal code

Employment/Title/Duties

Date of birth

How did you hear about my Transformational Coaching with Hypnosis?

What is the main reason you are seeking a coach?

Have you ever experienced hypnosis in the past. If so, what was the outcome?

Are you married? Do you have children? If so, how many and how old are the?

How satisfied are you with your life in the following areas? Use a scale of 1-5, with 1 being the worst and 5 is the best.

Happiness, Fullfillment and Satisfaction:
Home Life:
Relationships:
Body Image:
Spirituality:
Intimacy:
Work/Profession/Business:
Finances:

At this moment in your life, what do you most want?

Right now, what thing would you like to eliminate from our life?

In your personal life, list three things you simply tolerate.

Give three examples of issues at work that you currently tolerate.

Is there something you'd like to accomplish, but don't know how to go about it?

Any other ideas of results ... write them here.

How well do you take advise or work with someone to accomplish your goals?

Very Well

So so

Very badly

What kind of support do you prefer when challenges in your personal growth or thought process come up?

Good listening

Developing stratagies

A guided visualization process

Keeping a journal

Other support you prefer...

Is there anytyhing specific you hope to accomplish with this program?

Describe how committed you are to ensuring that this program works for you.

Are there any additional concerns or questions you'd like to address before getting started?

Responsibilities and Liability Release

1. I am willing to be guided through relaxation, visual imagery, hypnosis, and/or stress

reduction techniques. I am aware these modalities are non-medical in nature and it is my

responsibility to consult my regular doctor about any changes in my condition or changes in

my medication.

2. I understand the above modalities are not substitutes for regular medical care and I have

been advised to consult my regular medical doctor or health-care practitioner for treatment

of any old, new or existing medical conditions.

3. I understand that change is my own and complete responsibility. I understand that ALL

HEALING IS SELF HEALING and that Sheri Saunders is only a “facilitator” in the process

of helping me to solve my own problem(s). It is my responsibility to be open and honest,

provide accurate feedback and be forthcoming with details and information that may help

me achieve my outcomes.

4. I understand I may be assigned “homework” or be asked to make changes to my life by

my higher self in regard to complete or solidify any healing or changes begun in our session

today. I understand that this information and advice for change comes not from the Hypnotist,

but from my own higher being.

5. I understand that my facilitator may elect NOT to proceed with the session if she feels it is

not in their or your best interest to do so. My Facilitator is NOT liable for travel costs (airline,

hotel, etc.) associated with declining a session.

6. I understand that our session may be digitally recorded for my later use. I also understand

that in these types of metaphysical sessions, the energy in the room can affect the equipment and recording resulting in static or blank recordings.

Signature

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*Results may vary. Hypnosis results will vary from person to person. No individual result should be seen as typical. Sheri is not a healer, clients create their own healing with guidance. All hypnosis is self-hypnosis. Always consult a doctor for medical concerns.

INTAKE FORM - Online Coaching One-on-One

*Results may vary. Hypnosis results will vary from person to person. No individual result should be seen as typical. Sheri is not a healer, clients create their own healing with guidance. All hypnosis is self-hypnosis. Always consult a doctor for medical concerns.

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