Application Form | Hypnotherapy LA

First name

Last name

Email

Phone

Country of Residence

In your own words, what is the primary thing you are struggling with or wanting to change?

How long have you been experiencing this?

Which of these feels most true for you right now?

I keep self-sabotaging. Things start going well and something pulls me back.

I attract the same patterns. Same relationships, same situations, different faces.

I know what I want but can't seem to have it. The gap between desire and reality feels fixed.

I've tried everything and nothing sticks. Therapy, courses, coaches insight without lasting change.

I feel like I'm working against myself. Like there's a version of me underneath sabotaging the one on top.

What areas of your life are most affected? *

What have you already tried to create change? Therapy, coaching, courses, books, mindset work, anything relevant.

Have you ever experienced hypnotherapy, NLP or regression therapy before?

Yes

No

I've tried a combination of these

On a scale of 1–10, how ready are you to commit fully to this process right now? *

Is there anything else you'd like Punam to know before reviewing your application?

I confirm that the information I've shared in this application is honest and accurate

I understand that submitting this form does not guarantee a place in the Blueprint

I am happy for Punam to contact me by email regarding my application

Applications are reviewed personally by Punam. If your application is a strong fit, she will reach out to schedule a free 30-minute discovery call with no obligation to proceed.

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HYPNOTHERAPY

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