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Intake Questionnaire

Please provide the following information for our records. Leave blank any questions you would rather not answer, or would prefer to discuss with your therapist. Information you provide here is held to the strict standards of confidentiality.

What to expect

If this is your first initial consultation, please call me first before scheduling at +91-9011035444.

We will spend a few minutes in a complimentary consultation talking about your issues to ascertain that we have a rapport. You are not alone. Decide which type of session makes you feel most comfortable.

The first 60-minute session begins with completing this intake sheet. Together, we will target your issues and establish your goals for healing (weight loss, phobias, releasing toxic relationships, abuse, depression, anxiety, etc).

Most sessions include EFT (Emotional Freedom Technique) and a Guided Visualization. I will assist you in closing off negative neural pathways and creating new ones. For your thoughts are your reality.

Studies show effectiveness:

  • Psychoanalysis: 38% recovery (600 sessions)
  • Behavior Therapy: 72% recovery (22 sessions)
  • Hypnotherapy: 93% recovery (6 sessions)

Availability

  • In-person Sessions Appointments are in my home office in Caranzalem, Miramar, Goa and/or at the Rejuvenation Center in Candolim, Goa with prior bookings.
  • Online Video Sessions Please ensure an established Skype account, proper camera, mic set-up, and a comfortable, private setting.

Fees & Policies

  • Counseling and Therapy (60 mins) Rs. 3000
  • Counseling only (30 mins) Rs. 1500
  • Past Life Regression (2 hours) Rs. 6000
Terms & Conditions I am not responsible for any claims as each client differs in response. Fees paid will not be refunded. TIME IS MONEY. If you need to cancel or reschedule, please give a 48-hour notice.

1. Personal Information

2. Background & History

Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere?

Have you had previous psychotherapy?

Are you currently taking prescribed psychiatric medication (antidepressants or other)?

3. Legal, Release & Consents

Confidentiality

Being Free will not release any information to anyone without a written authorization from the client, except as provided by law. The client has a right to access any records of sessions. All requests for release of any information to a client or other person must be supported by a clear Authorization to Release Direction signed by the client and a picture ID of that client (if not requested in person). Only Dr. Anupama Sharma has access to client information. We realize that there are subjects and incidents that are so sensitive that extra efforts must be made to make the healing process comfortable for and accessible to all.

Release Statement

I hereby authorize Dr. Anupama Sharma to hypnotize me for the purposes outlined in this intake form and for the future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability and desire to effect change in myself. I understand that the results of my sessions depend greatly on my own serious participation, and that Dr. Sharma cannot offer any guarantee of the success of my treatment. I am aware, however, that Dr. Sharma will do everything in her power to ensure my success. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen hypnotherapy at this time. I understand that during the hypnotherapy session, Dr. Sharma may touch me as an anchoring technique. I hereby give my permission for such touch to take place during my session.