Issue Assessment and Goals Establishment

Please complete the form below in its entirety.  When you are finished, click Submit at the bottom of the page.

  1. (required)
  2. (required)
  3. Do you give ChangeWorks Hypnosis Center permission to contact your doctor(s) and/or therapist(s)? (Please note, in the event your issue requires a medical referral, answering "no" will prevent our working together.
  4. Do you associate any of these emotions with your issue? (Check all that apply.)
 

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