Forms | SOMA Hypnotherapy

top of page

SOMA HYPNOTHERAPY

About
Bio
Medical Hypnosis
Healing Stories
Events
Services/Fees
Contact
More

Use tab to navigate through the menu items.

Confidential Client Information

First Name

Last name

Emergency Contact's Name/Cell/Relationship

General Health

Notable physical/mental health issues and if you have a mental health diagnosis

Please note medications or other preparations you are taking

If applicable, do I have your permission to reach out to your primary care physician or specialist? If Yes, please provide the name and provider

What specific problem brings you in? (summarize briefly)

What is the goal you hope to achieve wit hypnotherapy?

Please note any other life difficulties that may be of concern

Alcohol / Drug Useage

Body Image

Communication

Depression

Eating Problems

Emotional Upset

Fears/Phobias

Guilt Feelings

Insomnia

Lying/Cheating

Money worries

Motivation

Pain -chronic/acute

Relationships

Sexuality

Stress/Tension

Weight Control

Briefly describe a place that brings you peace and why

Thanks for submitting!

Brit Lesnett, CCHt

Cell 415-246-1551 • Send email

ACHE# CHT519-127

Services provided are non-diagnostic and are complementary to the healing art services that are licensed by the State of California.

Hypnosis in Northern California and online worldwide. My clients are from Novato, Petaluma, Terra Linda, San Rafael, Greenbrae, Mill Valley, Sausalito, Rohnert Park, Santa Rosa, Sebastopol, Bodega Bay, Napa, Sonoma, Ukiah, Walnut Creek, Lafayette, Berkeley, Fremont, San Francisco, Nevada City, Grass Valley, Lake Tahoe, Modesto, Minden NV, Salem, OR, Portland, OR, Seattle, WA, Las Vegas, NV, Tulsa, OK, Branson, MO

bottom of page