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Hypnosis Massage Intake Form

If you are interested in booking a hypnosis massage, please complete the questionnaire below. A certified hypnotherapist will reach out to you to schedule a discovery call.

Name *

First

Last

Email *

Phone Number *

What day(s) and time of day work best for you to schedule a session? *

How did you hear about Hypno Massage? *

Referral
Google search
Social media
Yelp
Coupon Book
Body Spa
Other (please explain below)

If you selected other please explain here:

What are your goals for your session? *

Relaxation
Pain relief
Stress & anxiety reduction
Releasing trapped emotions & blockages
Overall wellness
More self care in my life!
Other

If you selected other please explain here:

What other service(s) are you interested in (now or in the future)? *

Massage Therapy
Hypnotherapy (with Valerian Healing Arts)
Art Therapy (with Valerian Healing Arts
Life Coaching (with Valerian Healing Arts)
Facials
Gua Sha
Body Treatments
Energy Healing
Nutrition Coaching & Gut Health (coming in Fall of 2023)

Do you have any allergies? *

Yes
No

If you have any allergies or sensitivities, list them here.

Please list any medical conditions, injuries, or pain you are experiencing. *

Are you under a Dr.'s care for any reason? *

Yes
No

If yes, please explain

Are you pregnant or nursing *

Yes, Pregnant
Yes, Nursing
No

What do you do for a living?

How would you describe your current health?

I'm in great health
No major health issues, but I'd like to do better
I'm really struggling with my health right now

What do you believe is holding you back from your ideal life/health?

Poor diet & lifestyle choices
Stress & Anxiety
Depression
Lack of motivation
Lack of energy
Health issues
Chronic pain
Lack of inspiration in life
Poor/lack of support group
Past trauma
Recent traumatic/stressful event(s)
Holding onto anger
Holding onto guilt
Other

If you selected other please explain here:

Do you smoke?

Regularly
On occasion
I don't smoke

How is your diet?

I eat healthy most of the time
I try to making healthy choices, but sometimes splurge to much
I really struggle with making healthy choices

Do you drink alchohol?

In Moderation
I indulge a little too much
I don't drink

How well do you sleep?

A full 7-8 hours a night
I sleep OK, but wake up frequently
I suffer from insomnia

What is your stress level?

Totally stress free
Moderate stress
Too much stress, I'm a high anxiety person

MASSAGE - How often do you recieve massages?

On a regular basis
Not enough!
This is my first massage

MASSAGE - What are some things you liked or did NOT like about your last massage?

MASSAGE - What areas would you like to have focused on?

MASSAGE - are there any areas you would like avoided?

MASSAGE - Please include in my Massage:

Facial Massage
Scalp Massage
Abdominal Massage

MASSAGE - What pressure do you prefer? Please note there is NO deep tissue during hypno-massage. If you prefer a deep tissue please book a deep tissue massage.

Light relaxation
Medium to firm

HYPNOSIS - Have you ever had a hypnotherapy session before?

Yes
No

If yes, please explain what was the focus of your session and if you felt it was effective?

Your hypno massage may include other modalities if appropriate. Please check any other treatments you are open to experience during your treatment

Lymphatic work
Vibro-acoustics (tuning forks/sound therapy)
Energy work
Aromatherapy
I am open to receiving any/all of these. I will ask questions if I'm not familiar with any of these therapies.

AROMATHERAPY - Goal for Aromatherapy (Zen Body & Skin only uses aromatherapy derived from plants, no synthetic scents are used)

No aromatherapy
Relaxation
Pain Relief
Energizing
Immune Boosting
Respiratory & allergy issues
Anti-Cellulite & Lymph movement
Anti-Aging
Spirituality

AROMATHERAPY - scents I am drawn to:

Floral (relaxing)
Citrus (uplifting)
Spicy (warming & Immune boosting)
Earthy (grounding)
Fresh or Minty (cooling and uplifting)
I like it all!

AROMATHERAPY - Other scents you are drawn to:

AROMATHERAPY - Scents you dislike:

I understand massage & hypnotherapist services are for therapeutic and wellness purposes only. All services are conducted by a licensed/certified professional . I understand this is not medical advice, is not meant to treat or cure any disease, and should not take precedent over a Medical Doctors instructions. I understand if I am experiencing a severe medical condition or unexplained pain I should seek out a medical doctor. *

I agree
I do not agree

I understand if for any reason I cannot make my appointment I will contact Zen Body & Skin as soon as possible to cancel or reschedule. (Thank you for your courtesy.) *

I agree
I do not agree

During my massage if anything feels painful or uncomfortable I will let my therapist know right away.

I agree
I do not agree

I have disclosed all allergies and health conditions that could affect my treatment. I take full resonsibilty for my body's response to treatment. *

I agree
I do not agree

If I am sick, have an active infection, new injury, or have been exposed recently to someone who is sick, I agree to reschedule my appointment to a later date. *

I agree
I do not agree

By hitting the submit button you confirm you've answered all questions to the best of your knowledge, as well as agree to our terms and conditions, cancellation agreement, and spa etiquette. *

I agree
I do not agree

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