Issue Assessment and Goals Establishment Please complete the form below in its entirety. When you are finished, click Submit at the bottom of the page. Your Name* First Last Today's Date* MM DD YYYY Describe your presenting issue:*When and under what circumstances did this issue begin?How has this affected your life?Has it ever been different?What specifically about your issue is leading you to seek help at this time?Are you on any medication or have you ever been diagnosed with a mental illness?Please provide the name(s) and contact information of your doctor(s) and/or therapist(s). (If a medical referral from this professional is required, due to the nature of your issue, you will be advised.)What other kinds of therapies have you tried?What lifestyle or attitude changes have been partially successful?Do you give ChangeWorks Hypnosis Center permission to contact your doctor(s) and/or therapist(s)? (Please note, in the event your issue requires a medical referral, answering "no" will prevent our working together.YesNoDo you associate any of these emotions with your issue? (Check all that apply.) Abandonment Fear Loneliness Grief Anxiety Happiness Boredom Relaxation Anger Romance Embarrassment Masculinity Glamour Satisfaction Loss Shame Frustration Security What is your 1 month goal regarding this issue(s)?What is your 6 month goal regarding this issue(s)?What is your 1 year goal regarding this issue(s)?What is your 5 year goal regarding this issue(s)?