Home
Services
Rosa Whipple
Weekly Events
Reviews
Contact Me

Home
Services
Rosa Whipple
Weekly Events
Reviews
Contact Me

Facebook Instagram

Body Mind Soul Healing Client Intake Form

Tell me more about you and your goals so I can better help you.

How did you hear about Body Mind Soul Healing?

Are you hard of hearing? If you normally wear a hearing aid, please use it as you will have your eyes closed and will not be able to lip-read during a session.

Do you wear contact lenses? During hypnosis your eyes will be closed for about 45 minutes. If your contacts will cause eye irritation, you may want to remove them before the hypnosis begins.

Primary Goals for Hypnosis

Weight Management Smoking Cessation Stress Release Anxiety Relief Habit Control (Drugs & Alcohol) Nail Biting Sleep Improvement Anger Sadness/Depression Motivation/Productivity Self Image (Positive self image and talk, self esteem) Study Skills Fitness/Nutrition Relationships (Self, Children, Partner, Family) Fears/Phobias Confidence Public Speaking

Have you ever been diagnosed with any of the following?

Schizophrenia Bi-Polar Manic Depression OCD (obsessive compulsive disorder) PTSD (post traumatic stress disorder) Brain Injury Clinical Depression Diabetes None of the Above

Are you taking any medications?

Are you under the care of a mental health professional?

Any previous experience with hypnosis?

Body Mind Soul Healing © Rosa Whipple (603) 477-2663 • April 18, 2026 6:43 pm

Facebook Instagram

Forms: Client Bill of Rights • Liability Waiver • Intake Form