How can I help?

All info provided are used to enhance the way I will assist you (in French or in English).

It is okay if you leave some fields empty, we can talk about it if needed later.

Hypnotherapy Intake Form

Personal Information

Please enter your name.

Please enter a valid email.

Please enter your primary goal.

Please select severity.





Please list medications or ‘None’.

Medical Contacts +

Lüscher Color Test 1

Select colors in order of preference:

Please select at least 7 colors.

Additional Personal Information +

Mental Health History +

Phobias +

Lüscher Color Test 2

Select colors in order of preference:

Please select at least 7 colors.
Please select a session format.





GDPR consent is required.
Health consent is required.
Trance consent is required.