Medical History Form Yager Mind Matrix®

Medical history form Yager Mind Matrix

Thank you for choosing Yager Mind Matrix! To ensure optimal preparation, I need a few details from you. Please fill out the following questionnaire thoroughly and completely, then send it back to us digitally via the button at least 48 hours before your session. Thank you very much!

Ms/Mrs/Mr

Last Name, first name

Date of Birth:

Adress:

Email:

Phone no

Mobile Phone

Profession

Names and ages of your children:

Any previous experience with mental techniques, relaxation techniques, hypnosis, self-hypnosis, or relaxation methods? If yes: Which ones, how many sessions, and with what success?

Please describe your problem/current challenge

In which situations does the problem become particularly acute? (Key points)

What is prevented by the problem in your life?:

What feelings does this trigger in you?

What does the problem force you to do?

What is your desired outcome of the treatment/What is your stated wish?

Are there any psychiatric diagnoses (depression, bipolar disorder, psychosis)?

Previous treatments relevant to the current problem (period, outpatient, inpatient, duration, success)

Relevant medications and dosage (sleeping pills, sedatives, strong painkillers, etc.):

How can you tell for sure that you have achieved your goal?

Thank you!

Medical history form Yager Mind Matrix

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