I help people to create more heaven in their lives. Enough with the hellish thoughts.

If you don’t hear back within a few days please email me. In person appointments will be held at La Boussole Medical spa in Joplin, Missouri. All other appointments will be held online through ZOOM.

Name

First Name

Last Name

Occupation

(if it doesn't accept that's ok, it's not required. If you have any troubles please email me)

Address

City

Postal or Zip Code

Cell

Relationship Status

If Spouse or Partner, Partners Name

If Children, Number Of Children and Ages

Close Relatives or Friends That have Passed, Your Relation To Them

Are you aware of my pricing? (Check pricing in menu options)

Have You Been At Hypnosis before

Yes

What Are You Hoping To Accomplish Through Hypnosis?

Do You Have Any Current Mental Or Physical Issues? Brief Description

If so are You Currently Taking Medications For These Issues?

Do You Have Any Religious Beliefs? Brief Explanation

Hypnosis Will Take Your Mind To Whatever Areas Need To Be Addressed. Are There Any Areas That Are Off Limits For You?

Do You Have Any Resistance To Different Forms Of Change?

Are You Willing to Be Truly Honest With Your Emotions And How You Actually Feel About Certain Situations? Successful Outcomes Are Dependent On This. Please Remeber This Is A Safe Space And All Sessions Are 100% Confidential.

Do You Have Any Fear Such As Water, That You Would Like To Avoid During The Visualization Process?

Where Did You Hear About The Real Healing Institute?

Anything Else You May Feel Is Relevant To The Upcoming Session?

Agreement To Terms

I hereby authorize, Michelle Sinclair, The Real Healing Institute, to hypnotize or use guided imagery with me for the purpose outlined in above reasons for coming to hypnosis/guided imagery and for anything else that comes up during the session. I understand the result of the session depends upon my own willingness to cooperate and that my level of participation equals the level of my success. I understand that hypnosis/guided imagery is not a medical or psychological procedure. I am aware and trust that Michelle Sinclair will do everything reasonable in her power to ensure my success and that she does not offer any guarantee as to the success of the session. I understand that all conversations are completely confidential. By checking this box, you agree that you have read, understand and agree ti the terms and conditions stated above.

I Agree

Todays Date

No fields are required for your form to be able to be submitted. If some of the text boxes are saying they aren’t accepted its ok, just leave it blank and submit.