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Client Information

Personal Information

Success Center Challenges Checklist

The Seven Keys to Self-Actualization Using Self-Hypnosis

  • Client Information
  • Personal Information
  • Success Center Challenges Checklist
  • The Seven Keys to Self-Actualization Using Self-Hypnosis

Client Information

The Client Information Intake Form consists of five Step. The first step is instructions and the second step concern your personal information. Step three contains the Challenges Checklist, please read each item on that page and put a Y (for yes) behind every item that applies to you (in any way), then go back and number each Y in order of priority. “1" is your highest priority, 10 is your lowest priority. It is okay to use more than one 1, more than one 2, but don’t make them all 1’s and 2’s. Do spread out your numbers. If an item doesn’t apply to you, leave it blank…. Don’t mark it a “10”. Step fourth briefly describes the Seven Keys. (There are only 7) On this page, number 1 has been entered for you on the Bronze Key blank, as it always has to be first. The rest of the blanks are to be numbered 2 through 7, using each number only once. Again, if they don’t apply to you, leave them blank. The last step is for office use only, please leave it blank. If you have any questions feel free to call us at Success Center, Inc. (818) 882-8512.

Personal Information

Name

Sex

Age

Date of Birth

Address

City

State

Zip Code

Home Phone

Home Hours

Work Phone

Work Hours

Cell Phone

E-mail

Employment History

Employed By

Employer Phone

Employer Address

Employer City

Employer State

Employer Zip Code

Occupation

Marital Status

Spouses Name

Anniversary Date

Family Member Information

Spouse Employed By

Children (age/sex)

Amount of Your Education & Degrees Held

Doctor's Name

Doctor's Phone

In Emergency Notify

Relationship

Emergency Address

Emergency Phone

List a Few Short-Term Goals

List a Few Long-Term Goals

Please Describe Any Prior Hypnosis Experiences

Religion Raised

Religion Now

Attend Services

Current Health Issues

Current Medications

How would you like your life to have changed in one year?

My most important challenge is:

In five years?

What is your ultimate goal in life?

Special Interests/Hobbies

Publications (which one?)

Radio/TV (Stations?)

Lecture (Business/Organization Name?)

Personal Referral (Who?)

Trade Show (Which one?)

Convention (Which one?)

Internet

Other

Are you associated with a business/organization which may need a speak or seminar leader?

Please Specify

I AM APPLYING FOR HYPNOSIS SESSION. I UNDERSTAND THAT MISSED APPOINTMENTS WILL BE FULLY CHARGEABLE TO ME AT REGULAR RATES. IF A 24-HOUR NOTICE IS GIVEN TO CHANGE APPOINTMENT, THERE WILL BE NO CHARGE.

Date

Agreement

Success Center Challenges Checklist

Instructions: Please read each item BELOW and check off every item that applies to you in any way in the box to the RIGHT of the item. (Example: Need more fun ✓) After you have finished checking each applicable item, go back and rate each checked item by the SCALE OF 1=HIGHEST TO 10=LOWEST in the blank field. (Example: Need more fun 2)

This page contains the Challenges Checklist, please read each item on that page and put a X (for yes) behind every item that applies to you (in any way), then go back and number each X in order of priority. "1" is your highest priority, 10 is your lowest priority. It is okay to use more than one 1, more than one 2, but don't make them all 1's and 2's. Do spread out your numbers. If an item doesn't apply to you. leave it blank....Don't mark it a "10".

Checklist

Other concerns:

Rate of Items Checked

The Seven Keys to Self-Actualization Using Self-Hypnosis

This page briefly describes the Seven Keys. (There are only 7) On this page, number I has been entered for you on the Bronze Key Blank, as it always has to be first. The rest of the blanks are to be numbered 2 through 7, using each number only once if they don't apply to you, leave blank.
1 AUTO-SUGGESTION AND SELF-HYPNOSIS………………………THE BRONZE KEY Develop heightened sensory awareness and the ability to better control your environment. Enhance emotional awareness, control and expression. Decision making skills and the Will to Learn are introduced. You will also begin increasing your ability to understand and remember the essence of what you read, see and hear.
MEMORY ENHANCEMENT…………………………………………. THE COPPER KEY Develop a photo/phonographic memory, mental data correlation, speed-reading, effective test taking techniques and instant math intuition. Improve memory for names and faces. Anything required for better learning ability is unlocked with this Key.
The Bronze Key must be taken before any other Key. The rest may be taken in any order desired. Problem-resolution and achievement of individual goals will continue in all Keys.

The Copper Key

CREATIVITY…………………………………………………………… THE SILVER KEY Learn to be inspired at will! Remove all mental/emotional blocks to effective public speaking, writing and problem-solving. Enhance special talents such as art, acting, musical performance and composition. Apply your newly awakened creative skills to all areas of your life!

The Silver Key

SUCCESS……………………………………………………………. THE DIAMOND KEY Remove any mental or emotional blocks to your personal and business success through hypnotic age regression. Develop the skills and motivation necessary to create the career you’ve always wanted! With the Diamond Key you can easily apply the powerfully persuasive communication tools of “Neuro Linguistic Programming” for maximum success in business and career-related areas.

The Diamond Key

BODY AWARENESS AND HEALTH TRANSFORMATION…………. THE GOLD KEY Develop abilities to manage stress, lower blood pressure, release excess weight. Your body cooperates with you to attain and keep your ideal shape and top health. Learn to release unnecessary discomfort, improve athletic abilities, enhance vision/hearing, and much more. Rejuvenation. The Hypnotic Fountain of Youth is available as a Gold Key Option.

The Gold Key

ESTABLISHING AND ENHANCING RELATIONSHIPS……………... THE RUBY KEY Singles learn to choose, attract and stay in a quality relationship with YOUR Right one (Matchmaking also available.) Already in a relationship? Make it even better! Parents, learn to be in a warm, positive relationship with your children--whether they be 5 or 45.

The Ruby Key

SPIRITUAL GROWTH…………………………………………… THE PLATINUM KEY Meet your Spirit Guides and Higher Self. Explore your past lives. Develop your psychic abilities. Select from among telepathy, astral projection, precognition and other special talents. Advance option: Psychic diagnosis and the Healing Touch. HELPER/HEALERS enhance communication, interpersonal and helping skills of all kinds.

The Platinum Key