Kathie Brodie, The Baggage Handler

“I can help you lose your baggage without going to the airport”
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General Questionnaire

Do you feel like your life is controlling you instead of you being in control of your life? Are things getting in your way of being happy and you just can't quite put your finger on what they are? Would you like to feel worthy and safe and comfortable with yourself and understand why you make the decisions you make? If those questions have sparked something deep within you, take a moment to fill out the following questionnaire, including contact information. It is set up so you can forward your answers to me by pushing "send" at the end of the form. Call for a free evaluation to help determine if this is the right step for you. 206.353.2178

Please take some time and be thoughtful about your answers when completing this form. I look forward to our no obligation phone visit. The phone visit will be your opportunity to ask me any questions that you may have. Also, it will be my opportunity to ask you any further questions so that I may know better how to serve you. Please have any questions ready so that we can make the most of our time together. If appropriate, we will set the time for your appointment during the phone visit.

I am excited about speaking with you.

Today's Date

Your Name

Your Email Address

Street Address

City, State, Zip

Phone numbers

What is the best way and time to contact you?

Do you have any fears / phobias?

Yes No

Which ones?

Are you presently experiencing...

Extreme anger Anxiety Phobias Sleeplessness Depression

I am presently feeling
overwhelming feelings of ...

other?

When you were growing up, did you feel like you fit in at school?

Yes No

When you were growing up, did you feel like you fit in at home?

Yes No

When you were growing up, did you feel like you fit in with other people in general?

Yes No

Do you feel like you are unworthy?

Yes No

Do you feel like life is unfair?

Yes No

Do you feel isolated from the world?

Yes No

Do you believe the universe is friendly or unfriendly?

Friendly Unfriendly

What issues are you trying to address with
hypnosis?

Have you ever tried hypnosis before?

Yes No

If yes, what were the circumstances?

Have you ever done any type of counseling before?

Yes No

If yes, what were the circumstances?

What do you imagine your life would be like if you could resolve the issue(s) that have been holding you back?

What do you imagine your life would be like if you don't resolve the issue(s) that have been holding you back?

What has gotten in the way of you making changes before?

How willing are you to open your mind to new ways of healing?

Not at all Maybe Quite a bit

How willing are you to discover what needs to he healed or corrected to eliminate this issue or concern from your life?

Not at all Maybe Quite a bit

How willing are you to seeing your life differently?

Not at all Maybe Quite a bit

Ask yourself: Am I willing to see the bigger picture?

Yes No

Ask yourself: Am I willing to imagine my life differently?

Yes No

Am I open to new possibilities, new ways of thinking, seeing, feeling about my life?

Yes No

Am I willing to look deeply into my past, work hard to clean it up (with assistance)?

Yes No

Am I willing to open up so that I can heal whatever is keeping me stuck or blocked from moving ahead in my life?

Yes No

Describe a peaceful place for you

A noted anthropologist studied ancient indigenous cultures and discovered in her research that the village healer or shaman used the following four questions as a common way of diagnosing the onset of dis-ease or illness. Think about them and answer them in the broadest sense.

When did you stop singing?

When did you stop dancing?

When did you stop being enchanted by stories?

When did you stop enjoying the sweet sound of
silence?

I understand that good and lasting results may require several hypnosis sessions, and that I may be required to practice self-hypnosis and/or listen to a reinforcement recording between sessions/at home. I am responsible for actively cooperating with, and participating in my program. Kathie Brodie , NGH Certified Hypnotist, shall not be held accountable for the results I attain. I understand that I may be referred elsewhere for proper treatment, and that my program may be terminated if deemed appropriate. I have read the client bill of rights, and I understand that all information about me will be kept strictly confidential.
I understand

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	Contact Kathie at Kathie@TheBaggageHandler.com Certified Hypnotherapist Inverse Wave Therapy Practitioner Metaphysician and Lightworker Level III Certified Reconnective Healer Reconnective Healer for Pets Reiki Master Author 18505 Firlands Way N, Shoreline, WA 98133 (located inside the Shoreline Community Acupuncture facility) Phone: 206-353-2178 • Fax: 206-546-1164