Case Study 00232 – 24 March 2026 – Customized Hypnotherapy Healing Program Intake
Client Discovery & Assessment Questionnaire
Purpose: To gather deep insight into the client’s emotional, mental, and behavioural patterns in order to design a personalized hypnotherapy program.
Section 1: Personal Awareness & Self-Perception
- How would you currently describe your relationship with yourself?
- What thoughts do you most frequently have about yourself?
- In what areas of your life do you feel “not good enough”?
- When did you first start feeling this way about yourself?
- What does self-love mean to you personally?
Section 2: Self-Worth & Identity
- Do you feel deserving of success, happiness, and love? Why or why not?
- What internal beliefs might be limiting your growth?
- How do you handle criticism or rejection?
- What roles or identities do you feel pressured to maintain?
- If you could redefine yourself, who would you become?
Section 3: Emotional & Mental State
- How often do you experience anxiety, stress, or low mood?
- What are your most common emotional triggers?
- How do you typically cope with overwhelming emotions?
- Have you experienced any past trauma or unresolved emotional pain?
- What emotions do you find hardest to express or process?
Section 4: Habits & Behaviour Patterns
- What habits do you feel are holding you back?
- When do these habits usually occur (time, situation, emotional state)?
- What do you gain (emotionally or mentally) from these habits?
- What habits would you like to build instead?
- Have you tried to change these habits before? What happened?
Section 5: Focus, Discipline & Motivation
- How would you rate your current level of focus and discipline?
- What tends to distract you the most?
- Do you procrastinate? If so, what are you avoiding?
- What motivates you when you feel aligned and productive?
- What does your ideal daily routine look like?
Section 6: Stress, Anxiety & Depression
- What situations cause you the most stress or anxiety?
- How does stress show up in your body and thoughts?
- Have you experienced periods of depression or emotional numbness?
- What support systems (if any) do you currently have?
- What would “healing” look like for you at the end of this program?
Practitioner Notes (Optional Add-On)
- Emotional intensity scale (1–10)
- Dominant limiting beliefs identified
- Core triggers and behavioural loops
- Suggested hypnotherapy techniques:
- Regression therapy
- Inner child healing
- Suggestion therapy
- Cognitive restructuring
- Habit reprogramming
Outcome Intention Statement (Client-Focused)
“By the end of this hypnotherapy program, I want to feel… (confident, calm, in control, disciplined, self-loving, etc.)”