Client Intake form Name *Email AddressPlease ONLY check fields that apply to you:Do you experience any discomfort while lying down on your back for more than 2 hours?Do you have a fear of heights?Do you experience any discomfort while sitting down for more than 2 hours?Do you have a claustrophobia?I need this information to customize the experience for youIf you are taking any prescription drugs, please specify below drug name and reasons.Do you have any illnesses that are being treated by a physician?Have you attempted hypnosis before? If yes, do you think you have been hypnotized?Date of agreed sessionSend Message