Application Form for Children


Fill out the form only if you are ready to make the payment and proceed with the sessions.

Full payment is required 24 hours before the session. If you cancel your appointment prior to your appointment, the money will be fully refunded. However, after using the first session, regardless you use the remaining sessions or not, the fee remains the same and there will be NO refunds. The fee is per program, not per session. Missed appointments without proper prior notice will count as used sessions.

The information you provide is strictly confidential. You get the same confidentially at Virginia Beach Hypnosis as you would get at your doctor’s office. Please answer all the questions with honesty. No need to be shy or embarrassed. I can help you better if I know all the facts upfront.

All fields are required.

I am aware of the cost of the service I am seeking. (Fees Page)

Method of Payment *
Today’s Date *
How did you find me? *
Child’s Full name and what would you like me to call him/her? *
Date of Birth *
Enter as : mm/dd/yyyy
Child’s Gender *
Street Address *
City *
State *
Zip *
Phone *
Alternate Phone
Email *
Repeat Email *
Enter the email again please, do not Copy and Paste
Child’s Education *
Child’s Academic Performance *
Names of Parents *
Parents Occupation *
Are the Parents together? *
Does the child have any Siblings? *
Names and Ages
Who is the child’s best Friend? *
Does the child have any imaginary friends? *
if yes, what is his/her name?
Does the child believe in angels, magic and Santa Claus? *
Does the child have any pets? *
If so name and type of pet.
Name of the child’s favorite TV character? *
What is the child’s favorite story? *
What activities makes the child happy? *
Please select preferred days for sessions *
Chose the preferred time for session *
Describe the current problem *
Describe the current problem. When did it start and did anything important happen in the child’s life at the time when the current problem started? This could be a major life change for example the parents separating, divorce, death in the family etc.
Virginia Beach Hypnosis Terms and Conditions
Agreement to Terms and Conditions *
By checking this box and submitting this application form, I confirm that I have read, understood and agree to the above Terms and Conditions.

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