Please fill out this short form:

STRUCTURED HYPNOTHERAPY PROCESS

This is the short form we need filled out to work together. All fields are required. Only I, Dr. Flavio have access to, see and read this form. All information is secure and only used for therapeutic purposes.

Do you have children?

Yes

Do you see a physician regularly (at least once a year)?

Yes

Do you take prescribed medications?

Yes

Do you sleep well?

Yes

Have you been diagnosed with a mental illness or disorder?

Yes

Have you ever been hospitalized for a mental issue?

Yes

Do you have a close family member diagnosed with a mental disorder?

Yes

Have you ever considered ending your life?

Yes

Have you been in therapy before, or now?

Yes

Have you been to a hypnotist before?

Yes

If you have been to a hypnotist, did you feel hypnotized?

Yes

Never been to a hypnotist

Do you want to make a change within yourself?

Yes

Not sure

Do you BELIEVE you can succeed and achieve your goals?

Yes

Not sure

Is it easy for you to wake up in the morning?

Yes

Sometimes

Do you consume pornography?

Yes, regularly

Sometimes

Never

Your body weight is:

About right for me

Overweight or obese

Underweight

Do you feel happy?

Yes

Sometimes I do

Can't remember the last time I felt happy

Do you use non-prescription substances such as pot, coke, etc

Yes

Sometimes

Your finances, as it relates to stress levels:

I am financially stable, no worries

Finances is a huge problem for me

It is tough, but I do not worry about it

Other

Do you feel now, or have you been burnt out?

Yes, now

Yes, in the past

No, never

Do you feel "heart-broken"?

Yes, now

Yes, in the past

No, I feel fine

Do you consider yourself healthy?

Yes

Need changes urgently

Do you typically remember your dreams?

Yes, often, if not all the time

I rarely remember a dream

Never

Flavio B. Souza-Campos, B.A., M.D., Ph.D.

Awesome Relations Coaching & Hypnosis

Main office in Miami Springs, Florida

Service Locations In:

Coral Gables, Doral, Aventura, Plantation and Online

305-505-3279

[email protected]

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Copyright 1996-2026:

Flavio B. Souza-Campos, B.A., M.D., Ph.D.

Awesome Relations Coaching & Hypnosis

Main office in Miami Springs, Florida

Service Locations In:

Coral Gables, Doral, Aventura, Plantation and Online

305-505-3279

[email protected]

We would love to serve you