Foundation (Required)

USD 250.00

MJ Ims

Certified Hypnotherapist & MBI Practitioner

75 Minutes

Personal Information

First Name

Please enter your first name.

Last Name

Please enter your last name.

Please enter a valid email.

Phone Number

Please enter your phone number.

Date of Birth

Please select a valid date of birth.

Time Zone

Additional Information

Intake Form

Before We Begin

This form helps us make the most of your first session together. Your responses are kept private and will only be used to shape your experience at Harmonium. Take your time — there are no right or wrong answers, just a starting point for the work ahead.

Full Name

Please enter your response.

Pronouns

Please enter your response.

Email Address

Please enter your response.

Phone Number

Please enter your response.

Physical / Mailing Address

Please enter your response.

Date of Birth

Please enter your response.

Emergency Contact Name / Relationship / Phone Number

Please enter your response.

Personal Background

The following questions help us understand your life context and current circumstances. This information is kept private and helps us get a fuller picture of where you are coming into this work.

Employer / Job Title

Please enter your response.

Medical / Mental Health Notes

Please enter your response.

Fears / Phobias

Please enter your response.

A Little About You

This section is about you — what you're carrying, what you're reaching for, and what you already know works. Just a chance to share what feels relevant before we meet.

What are your primary goals for our sessions?

Please enter your response.

What are your previous efforts to move towards these goals?

Please enter your response.

Is there anything that has been keeping you from reaching your goals?

Please enter your response.

Do you have any prior experience with NET (neuro-emotional technique) or Hypnosis? If so, please explain.

Please enter your response.

What is your learning style?

Auditory (listening)

Visual (seeing)

Kinesthetic (touching)

I don't know

Please select your response.

How did you hear about our services?

Family / Friend

Social Media

Google

Event / Workshop

Other (please explain)

Please select your response.