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Breathwork
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Rosa Whipple
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Home
Services
Services
ASCEND
Breathwork
Wildlight Way Hypnosis
Chakra Healing
Phone Consultation
Grounded Again
Rosa Whipple
Weekly Events
Reviews
Contact Me
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Wildlight Alchemy Client Intake Form
Tell me more about you and your goals so I can better help you.
How did you hear about Wildlight Alchemy?
Referral
Social Media
Google Search
Other
Are you hard of hearing? If you normally wear a hearing aid, please use it as you will have your eyes closed and will not be able to lip-read during a session.
No
Yes
Do you wear contact lenses? During hypnosis your eyes will be closed for about 45 minutes. If your contacts will cause eye irritation, you may want to remove them before the hypnosis begins.
No
Yes
Primary Goals / Intentions:
Weight Management
Smoking Cessation
Stress Release
Anxiety Relief
Habit Control (Drugs & Alcohol)
Nail Biting
Sleep Improvement
Anger
Sadness/Depression
Motivation/Productivity
Self Image (Positive self image and talk, self esteem)
Study Skills
Fitness/Nutrition
Relationships (Self, Children, Partner, Family)
Fears/Phobias
Confidence
Public Speaking
Have you ever been diagnosed with any of the following?
Schizophrenia
Bi-Polar
Manic Depression
OCD (obsessive compulsive disorder)
PTSD (post traumatic stress disorder)
Brain Injury
Clinical Depression
Diabetes
None of the Above
Are you taking any medications?
No
Yes
Are you under the care of a mental health professional?
No
Yes
Any previous experience with hypnosis, breathwork, energy healing?
No
Yes
Submit
Wildlight Alchemy Rosa Whipple (603) 477-2663 • October 24, 2026 9:23 am
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Forms: Client Bill of Rights • Liability Waiver • Intake Form
