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New Client Questionaire

 

BCS Marketing PTY LTD, TA Happy U HQ/Central Coast Modern Hypnosis  sometimes requests health and other sensitive personal information about you to evaluate your fitness and your ability to participate safely in our live and online events. This information is also used to assist us and you to determine what goals and aspirations you seek to achieve through our events.

 

We will not communicate this information to a third party without your consent.

 

By filling out the following questionnaire, you agree to our collection and use of the information requested to tailor your appointment to your individual needs.

 

If you prefer that we do not collect and process this information, we may not be able to provide the best response, treatment and recommendations.

 

Click the button below to start.

Start

Question 1 of 12

Please enter your full name and the date and time  of your appointment.

 

Question 2 of 12

What is you postal address?

Question 3 of 12

Best Contact Number

Question 4 of 12

Date of Birth?

Question 5 of 12

Please list all medications that you are currently taking.

Question 6 of 12

What are you struggling with right now?

Question 7 of 12

What do you most want from working with me?

Question 8 of 12

What are the biggest obstacles you are faced with in creating your desired outcomes?

 

Question 9 of 12

If these obstacles were resolved what would that mean for you? 

Question 10 of 12

What would your life look like if your could overcome your current challenges?

Question 11 of 12

How would you know if your session was successful? What would have to happen?

Question 12 of 12

On a scale of 1-10 how committed are you to achieving your ultimate success in the above mentioned areas?

Confirm and Submit