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Emotion Code
Body Coding
Spiritual Mentorship
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Reading via YouTube
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Home
Services
Emotion Code
Body Coding
Spiritual Mentorship
Hypnosis
Reading via YouTube
Phone Reading
About
Booking
Contact
G88D Vibrations Intake Form
Booking
Contact
G88D Vibrations Intake Form
Home
Services
Emotion Code
Body Coding
Spiritual Mentorship
Hypnosis
Reading via YouTube
Phone Reading
About
Home
Services
Emotion Code
Body Coding
Spiritual Mentorship
Hypnosis
Reading via YouTube
Phone Reading
About
Booking
Contact
G88D Vibrations Intake Form
Booking
Contact
G88D Vibrations Intake Form
G88dvibrations Intake Form
Date
MM slash DD slash YYYY
Name
First
Middle
Last
Phone
Email
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
How did you hear about us?
Medical and Emotional History
Which of the following are you currently experiencing/have experienced in the last 90 days as it applies to your physical health? Please check all that apply.
Allergies
Body Aches
Body Pain
Diabetes
Epilepsy
Flushing/Blushing
Headaches
Hearing Problems
Heart Problems
IBS
Low Energy
Migraines
Nail Biter
Smoker
Unexplained Pain
*Please list any additional thoughts or concerns you may have about your health.
Which of the following are you currently experiencing/have experienced in the last 90 days as it applies to your fears? Please check all that apply.
Animals
Avoid Cracks
Bridges
Birds
Body Fluids
Bugs
Dentist
Doctors
Dogs
Driving
Elevators
Escalators
Flying
Frogs
Germs
Going Out
Hate
Heights
Highways
Intimacy
Insects/Sting
Lightning
Lizards
Men
Public Speaking
Not Pleasing Others
Sight of Blood
Snakes
Spiders
Stairs
Surgery
Test Anxiety
Water/Swimming
Women
Other*
None of the above
*Please list any other fears or any additional thoughts you may have about your fears.
Which of the following are you currently experiencing/have experienced in the last 90 days as it applies to what you believe ails you? Please check all that apply.
Alcohol use/abuse
Angry Thoughts
Anxiety
Being alone
Being Touched
Chewing Mouth
Closed Spaces
Depression
Do/Enjoy Drugs
Easily Embarrass
Feel Inadequate
Hair Pulling
Hair Twisting
Hear Mumbling
Hear Voices
Highway Anger
Hand Washing
Insomnia
Impulsive Behavior
Missing Time
Mood Swings
Negative Thoughts
Nightmares
Panic Attacks
Past Abduction
People Too Close
Poor Concentration
Poor Memory
P.T.S.D.
Rambling Thoughts
Recurring Dreams
Skin Picking
Suicidal Thoughts
Other*
None of the above
*Please list any other thoughts or any additional thoughts you may have about your mental attitude.
Which of the following would you like to include in your awareness shift? Please check all that apply.
Control Alcohol Abuse
Control Cancer
Control lBS
Control Pain
Control Stress
Control Drug Use
Creativity
End Grief
Enhance Learning
Find your Joy
Healing
Increase Energy
Improve Energy
Improve Study Habits
Increase Sales
Lose Weight
Peace
Personal Healing
Positive Thinking
Rid Writer's Block
Self Confidence
Self-Hypnosis
Sleep Better
Spiritual Growth
Sports Enhancement
Stage Fright
Stop Nail Biting
Stop Smoking
Stop Test Anxiety
Other*
None of the above
*Please list any other desired changes or any additional thoughts you may have.
CONFIDENTIALITY AND CLIENT ACKNOWLEDGEMENT
I understand and acknowledge that hypnosis is not and does not replace medical treatment. G88dvibrations LLC practitioners are not medical doctors and, as such, practitioners do not diagnose conditions. Hypnosis and other modalities of healing work well in conjunction with traditional medical treatments. G88dvibrations LLC recommends seeking the advice of a medical doctor before beginning any type of treatment plan. G88dvibrations LLC does not record sessions and keeps client data in the strictest of confidence. We do not disclose any information regarding your sessions, except in cases where we are compelled through a court order or subpoena with which we are bound to comply. If you wish for us to discuss any details of your treatment with a referring physician or other individual, we will require your explicit consent in order to do so out of respect for your privacy.
Consent
I understand and acknowledge that hypnosis is not and does not replace medical treatment.
Date
MM slash DD slash YYYY
Print Name
First
Middle
Last