HYPNOTHERAPY WORKS

            SONYA NAULTA, MSW, CERTIFIED CLINICAL HYPNOTHERAPIST

 

Professional ~ Holistic ~ Ethical

 

Hypnotherapy Works services are individualized clinical hypnosis programs designed to help you reach your goal(s). Each program is tailor-made for you, based on what you want to have happen in your life. Listed below are some of the issues typically brought to a hypnotherapy session.

 

____stop smoking        ____lose weight           ____reduce stress        ____anxiety        ____depression            ____phobia(s)       ____nail biting          ____illness      ____other (What do you want to change in your life?)________ ___________________________________________________________________________________________________

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​Some clients simply want to improve something in their lives, such as the following:

____sleep        ____relationships          ____sports performance           ____health     ____work habits          ____memory                ____creativity               ____attitude

____other (What do you want more of in your life?) _____________________________________ _____________________________________________________________

​Consent Form 

Permission to be hypnotized statement:

I, ________________________________________, give my consent to be hypnotized by Certified Clinical

                      (print your name above)

Hypnotherapist, Sonya Naulta, MSW, on this date ____________________________________.

 

Agreement to pay fee for services statement:

I further consent to pay Certified Clinical Hypnotherapist, Sonya Naulta, MSW, for services rendered.

Sign here: ____________________________________​ 

 

This is a confidential client intake form used only for the specific purpose of providing clinical hypnotherapy services to the individual requesting my services. Information gathered here is protected under HIPAA Law and will not be disclosed to any third party for any reason.  Payment in exchange for services is expected prior to or at the time of services. If a package is purchased, the client receives a written guarantee* (see disclosure at bottom of page.)

 

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​As a client of Hypnotherapy Works, you can expect the highest quality of services, backed by twenty years of successful therapy practice. Sessions are sold as a package, or, a la’ carte. The package comes with a Satisfaction Guarantee* and is recommended to ensure efficacy of your program. Research on therapies like behavior modification and bio-feedback indicates that repetition and positive reinforcement of desired behavior increases the likelihood of permanent change. Hypnosis is the tool-of-choice for safe, immediate and effective transformation.​

 Neural Pathways:  Behavior is learned and can be un-learned, with the right tools. A habit is simply a behavior that has been practiced and reinforced, consciously and unconsciously, over a period of time. Some habits are good, like brushing your teeth every day. Some habits are detrimental, like eating a half-gallon of ice cream every night before bedtime. The human body gets used to certain behaviors, or is conditioned to respond a certain way to triggers in the environment. Sometimes, we feel like slaves to our bodies, confusing our wants and needs. Taking the path of least resistance, we succumb to our base selves. Immediate, short-term gratification overrules the human capacity for logic and reasoning.​

Hypnotherapy Works Package

Session 1                                       Education

                                                       Demonstration

                                                       Interview

                                                       Hypnosis

                                                       Closure & Test

 

Session 2                                       Follow-up Interview (one-to-two weeks later)

(recommended)                            Hypnosis

                                                       Closure & Test

 

Session 3                                       Check-up Interview (a month later)

(optional)                                       Hypnosis

                                                        Closure & Test

Package price: $250 (For guarantee, payment in full at Session 1 is expected.)

A la’ carte Session(s) price: $100 each ($25.oo retainer fee included in pricing.)​

Satisfaction Guarantee* for pre-paid package of Hypnotherapy Works individualized program(s)- If your old behavior returns, or, should you need a refresher session in the future, there is no charge for one repeat hypnotherapy session. (Repeat session is based on original program.)

 

CLIENT NAME:_________________________________ DATE: _________________________

 

Address: _______________________________________________________________________

 

Phone # :_______________________ Occupation:______________________________________

 

Where did you grow up? __________________________________________________________________

 

What are a few of your favorite stories? ______________________________________________________

 

 ______________________________________________________________________________________

 

Tell me a little bit about a special place you have been or you would like to visit: _____________________

 

 ______________________________________________________________________________________

 

Tell me about a memory or thought that makes you happy or peaceful when it crosses your mind: ________

 

 ______________________________________________________________________________________

 

What are a few of your LIKES? ____________________________________________________________

 

What are a few of your DISLIKES? _________________________________________________________

 

Describe a walk on the beach: _____________________________________________________________

 

______________________________________________________________________________________

 

Who are the most important people in your life? _______________________________________________

 

______________________________________________________________________________________

 

Where is the place that you feel the most relaxed, safe & comfortable? _____________________________

 

When you are the person you want to be, how will your life be DIFFERENT? _______________________

 

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What will others notice first about the improved you? ___________________________________________

 

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