Name
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First Name
Last Name
Email
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Date of Birth
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Age
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Mobile Number
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Names and Ages of Children and Spouse/Partner
How do you like to relax?
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What is your favorite colour?
List any fears or phobias
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Do you experience any compulsive tendencies or addictions?
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List any current health problems
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Is a doctor treating you?
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Yes
No
If yes, please give details
Have you ever been treated by the Mental Health services? Or taken anti depressants?
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Please list any particularly significant or traumatic life events
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List any prescribed or non prescribed medications you are currently taking, including alcohol, cigarettes etc…
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What is the emotional and psychological health of your parents?
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Do you follow a Spiritual, Religious practices or meditation? (It’s not a pre-requisite by the way!)
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Please list any other conditions occurring in your life that you believe are negatively affecting you in any way. Use as much space as you want to tell me the details of your concerns, needs or fears.
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At this moment in time, why are you seeking help with Ryan Scott Performance ? Please be as specific as you can (curiosity is ok but curiosity about what?)
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What are your long term goals in Golf?
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What do you feel you need to do to reach these goals?
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What would you say is the strongest part of your game?
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When you are playing/performing at your best, what is it you feel you are doing well?
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Key words to describe what you are feeling when you are Performing well?
What would you say is the weakest part of your game?
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When you are under performing, what is it that you feel could be better?
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Key words to describe what you are feeling when you are under performing?
What previous experiences of Hypnotherapy, Regression and/or meditation do you have?
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What would you rate your level of anxiety before a tournament? (1 being least, 10 being most)
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What would you rate your ability to deal with pressure (1 being least, 10 being most)
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What is your biggest fear in golf (if any)?
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How do you feel these anxieties, nerves and/or fears impact your ability to play your best golf?
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Do you have a technical swing coach and if so what are you working on at present?
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What ball flight do you prefer to use?
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How much do you focus on technique when you play golf i.e swing thoughts?
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Do you have a strength and conditioning programme?
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If so how many times per week do you workout?
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What would you rate your current level of strength and conditioning? (1 being the least, 10 being the most)
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What would you rate your current course management skills (1 being least, 10 being the most)
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What are your strengths and weakness with course management?
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Do you use a stats package and if so which one?
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Can you give an overview of your knowledge and experience using stats?
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What is your current on-course Nutrition and Hydration plan?
How would you describe your short game performance?
What areas of your short game do you feel are strongest?
What areas of your short game do you feel are weakest?
Ultimately, what would you like to achieve from these sessions?
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Is there anything else that you think I should know?
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Release Statement (terms and conditions)
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I hereby authorise Ryan Scott to help to Hypnotise me for the purposes outlined in this intake form, and for future purposes that I may request. I understand that Hypnotherapy Therapy is not a medical procedure and that no medical benefits are being offered to me. I understand that the success of my Hypnotherapy and Regression Therapy depends on my ability to relax and my desire to create change in myself. I understand that, because the results of the sessions depend on my own serious participation, Ryan Scott cannot offer any guarantee of the success of my treatment nor am I entitled to any refund of monies paid. I am aware, however, that he will do everything reasonable in his
ability to ensure my success.
Date
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