FORM HIPNOTHERAPI

1. Persiapan / preparasi/ preinduksi

DATA KLIEN
Nama lengkap : .............................................................................................................................................
Tanggal lahir : ...............................................................................................................................................
Pendidikan : ...................................................................................................................................................
Pekerjaan : .....................................................................................................................................................
Agama : ............................................................................................................................................................
No. Telpon/: Handphone : .......................................................................................................................
Alamat : ...........................................................................................................................................................
.............................................................................................................................................................................
DATA ORANGTUA/ WALI/ SUAMI
Nama lengkap : .............................................................................................................................................
Tanggal lahir/umur : .................................................................................................................................
Pendidikan : ...................................................................................................................................................
Pekerjaan : .....................................................................................................................................................
Alamat : ...........................................................................................................................................................
No. Telpon/Hp : ...........................................................................................................................................

Pernyataan Mendalam Seputar Kesehatan

Keluhan yang dirasakan ...........................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
Harapan setelah dilakukan hipnotherapi ..........................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
Tuliskan :
warna favorit :

1. ........................................................................................................................................................................

2. ........................................................................................................................................................................

3. ........................................................................................................................................................................
warna yang disukai :

1. ........................................................................................................................................................................

2. ........................................................................................................................................................................

3. ........................................................................................................................................................................

tempat favorit :

1. ........................................................................................................................................................................

2. ........................................................................................................................................................................

3. ........................................................................................................................................................................

hal yang tidak disukai dalam hidup/rasa takut/phobia :

1. ........................................................................................................................................................................

2. ........................................................................................................................................................................

3. ........................................................................................................................................................................

kegiatan/kenangan yang paling menyenangkan

1. ........................................................................................................................................................................

2. ........................................................................................................................................................................

3. ........................................................................................................................................................................

kegiatan penting dalam hidup

1. ........................................................................................................................................................................

2. ........................................................................................................................................................................

3. ........................................................................................................................................................................

Sebutkan hal yang ingin dikerjakan dengan lebih baik.................................................................

.............................................................................................................................................................................

Jika bisa memilih kembali, anda ingin menjadi ...............................................................................

 Learning channel :

o Visual
o Auditif
o Kinestetik

PERNYATAAN PERSETUJUAN KLIEN

Bersama ini, saya yang bertandatangan dibawah ini, oleh karena kesadaran sendiri
menyatakan diri bahwa menyetujui menjalani hypnotherapy oleh……….....…………….
……………………........................ (terapis) di…………………………………………………….………………
(Nama tempat/klinik) untuk mengatasi masalah……………………………………………………
...........................................................................................................................................................................

Saya memahami bahwa keberhasilan hypnotherapy sangat bergantung kepada

kemauan saya untuk rileks serta kemauan yang kuat dari dalam diri saya untuk berubah
sesuai dengan yang saya harapkan dengan didampingi oleh terapis. Saya berkeyakinan
penuh bahwa terapis berusaha melakukan segala upaya secara maksimal serta
professional dalam menangani masalah saya tersebut.

……………………………, …………………………………..

(………………………………………………………..)