Hypnosis Responsiveness Questionnaire

Your Name

Have you ever been hypnotized?

Have you ever walked or talked in your sleep?

Are you basically a trusting person?

Do you have a vivid imagination?

Do you daydream, fantasize or have real dreams?

Are you able to concentrate on an idea or thought?

Are you open to new ideas?

Are you able to get in touch with your emotions easily?

Are you able to follow basic directions?

Are you able to see or imagine images when reading something without pictures?

Are you a spiritual and/ or religious person?

Have you ever meditated?

Are you able to sit or lie still for a period of time?

If you were to imagine sucking on a sour, bitter, juicy lemon, would the thought alone cause you to salivate, swallow or pucker?

Proud Member of the International Hypnosis Association & the National Guild of Hypnotists

Please provide your name and phone number with area code, and a staff member will contact you, typically within one business day.

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