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Difficulty meeting people  FORMCHECKBOX  FORMTEXT   Easily influenced  FORMCHECKBOX  FORMTEXT   other  FORMTEXT       FORMTEXT   On-line dating questions  FORMCHECKBOX  FORMTEXT   Health concerns  FORMCHECKBOX  FORMTEXT   Want to quit smoking  FORMCHECKBOX  FORMTEXT   Need help w/profile  FORMCHECKBOX  FORMTEXT   Low energy  FORMCHECKBOX  FORMTEXT   Smoked how long  FORMTEXT       FORMTEXT   Stress & anxiety problems  FORMCHECKBOX  FORMTEXT    Take food supplements Y FORMCHECKBOX  N FORMCHECKBOX  FORMTEXT   How much per day  FORMTEXT       FORMTEXT   Has difficulty relaxing  FORMCHECKBOX  FORMTEXT   Frequently sick  FORMCHECKBOX  FORMTEXT   Difficulty sleeping  FORMCHECKBOX  FORMTEXT   No fun in life  FORMCHECKBOX  FORMTEXT   Allergies  FORMCHECKBOX  FORMTEXT   Can t fall asleep  FORMCHECKBOX  FORMTEXT   Overly anxious  FORMCHECKBOX  FORMTEXT   Physical pain  FORMCHECKBOX  FORMTEXT   Wake up frequently  FORMCHECKBOX  FORMTEXT   Worries too much  FORMCHECKBOX  FORMTEXT   Blood pressure High FORMCHECKBOX  Low FORMCHECKBOX  FORMTEXT   Can t fall back to sleep  FORMCHECKBOX  FORMTEXT   Fearful  FORMCHECKBOX  FORMTEXT   Menopause difficulties  FORMCHECKBOX  FORMTEXT   Bad dreams  FORMCHECKBOX  FORMTEXT   Frequent negative thoughts  FORMCHECKBOX  FORMTEXT   PMS  FORMCHECKBOX  FORMTEXT   Hard to get up in mornings  FORMCHECKBOX  FORMTEXT   Feels depressed  FORMCHECKBOX  FORMTEXT   Irritable bowel syndrome  FORMCHECKBOX  FORMTEXT   Mental processes slow  FORMCHECKBOX  FORMTEXT   Nervous  FORMCHECKBOX  FORMTEXT   Headaches  FORMCHECKBOX  FORMTEXT   Poor memory  FORMCHECKBOX  FORMTEXT   Negative reactions to stress  FORMCHECKBOX  FORMTEXT   Other  FORMTEXT       FORMTEXT   Poor concentration & focus  FORMCHECKBOX  FORMTEXT   Too pessimistic  FORMCHECKBOX  FORMTEXT   Aging too fast  FORMCHECKBOX  FORMTEXT   Read too slow  FORMCHECKBOX  FORMTEXT   Communication & speech  FORMCHECKBOX  FORMTEXT   Improved spiritual connections  FORMCHECKBOX  FORMTEXT   Studying is dull  FORMCHECKBOX  FORMTEXT   Difficulty expressing self  FORMCHECKBOX  FORMTEXT   Wants to know life s purpose  FORMCHECKBOX  FORMTEXT   Poor study habits  FORMCHECKBOX  FORMTEXT   Difficulties public speaking  FORMCHECKBOX  FORMTEXT   Wants to meditate  FORMCHECKBOX  FORMTEXT   Poor retention  FORMCHECKBOX  FORMTEXT    Fears  FORMCHECKBOX  Lack skill  FORMCHECKBOX  FORMTEXT   Connect spiritual guides  FORMCHECKBOX  FORMTEXT   Exam anxiety  FORMCHECKBOX  FORMTEXT   Reluctant speaking in groups  FORMCHECKBOX  FORMTEXT   Discover inner resources  FORMCHECKBOX      Date_______________ Name _________________________________________ Phone # ____________________ Joy Reichard * Transformative Hypnotherapy * 650-692-6165 *  HYPERLINK "mailto:jreich14@sbcglobal.net" jreich14@sbcglobal.net * www.transformativepathways.com )Hj%kd$$Iflֈh ,(@ (4 ( t0644 la$If $If^gdW!,.0>@\^`bdxȢӚ⚈vdYR hrRrh ;jhrRrh ;U#jGhg&h ;CJUaJ#jчhg&h ;CJUaJ#j]hg&h ;CJUaJh ;CJaJ jh[TXh ;UmHnHuj]h[TXh ;U h[TXh ;jh[TXh ;Uh ;hFvh 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D 0JEnter a number between 1 to 10, with 10 being the highest level of concerntDText5D 0JEnter a number between 1 to 10, with 10 being the highest level of concernvDeCheck63D 0JEnter a number between 1 to 10, with 10 being the highest level of concernxDeCheck112$$If!vh55@ 5(54 5(5 #v#v@ #v(#v4 #v(#v :Vl t655@ 5(54 5(5 D 0JEnter a number between 1 to 10, with 10 being the highest level of concerntDText6D 0JEnter a number between 1 to 10, with 10 being the highest level of concernvDeCheck64D 0JEnter a number between 1 to 10, with 10 being the highest level of concernxDeCheck113$$If!vh55@ 5(54 5(5 #v#v@ #v(#v4 #v(#v :Vl t655@ 5(54 5(5 D 0JEnter a number between 1 to 10, with 10 being the highest level of concernvDeCheck19vDeCheck20D 0JEnter a number between 1 to 10, with 10 being the highest level of concernvDeCheck65D 0JEnter a number between 1 to 10, with 10 being the highest level of concernxDeCheck114$$If!vh55@ 5(54 5(5 #v#v@ #v(#v4 #v(#v :Vl t655@ 5(54 5(5 D 0JEnter a number between 1 to 10, with 10 being the highest level of concernvDeCheck21D 0JEnter a number between 1 to 10, with 10 being the highest level of concernvDeCheck66D 0JEnter a number between 1 to 10, with 10 being the highest level of concernxDeCheck115$$If!vh55@ 5(54 5(5 #v#v@ #v(#v4 #v(#v :Vl t655@ 5(54 5(5 D 0JEn