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Vance Romane

Assessment and Evaluation

Please fill out the assessment and evaluation form below, so Romane can determine if he can help you.

If you prefer you can download a PDF copy here.

    First Name (Required)

    Last Name (Required)

    Email (Required)

    Phone (Required)

    Address Line 1 (Required)

    Address Line 2

    City (Required)

    Province/State (Required)

    Postal/Zip Code (Required)

    Marital Status (Required)

    Age (Required)

    Sex (Required)

    Number of Children (Required)

    Referred by

    Education: Last grade completed (Required)

    Occupation (Required)

    Medical History: Please list any diseases, allergies, surgeries or medications (Required)

    Habits: Please check all that apply:

    Other Habits:

    How good do you feel about yourself? (Required)

    What would make you feel better? (Required)

    Any current stress or worries? (Required)

    Your General Health is? (Required)

    Are you in physical discomfort? (Required)

    If yes, please describe condition:

    Present Problem (in your own words): (Required)

    Why is it important for this change to occur? (Required)

    Do other members of your family have the same problem? (Required)

    Duration of problem (Required)

    Severity of problem (Required)

    Times when problem is most evident (Required)

    What have you done previously to try and solve the problem? (Required)
    (A) Professional help

    (B) Medications taken

    (C) Other methods

    Results of these efforts (Required)

    Are you aware of any emotional problems or physical conditions that might account for your problem? (Required)

    What would happen if you never achieved this goal? (Required)

    Briefly describe a time in your life when you felt completely relaxed and happy: (Required)

    Have you ever been hypnotised? (Required)

    If yes, how?

    Do you have any of Romane’s recordings? (Required)

    If yes, which ones:

    Why have your chosen hypnosis? (Required)

    What do you know about hypnosis? (Required)

    Is there anything that you have not yet told me, which you think I should really know?

    Are there any specific thoughts you want Romane to give you during hypnosis while your mind is focused?

    By clicking the SUBMIT button you agree:

    1. M.V.P. Ltd., Romane does not offer any programs as a supplement to or replacement for any medical or psychological services rendered for any mental, emotional or physical disorder.
    2. M.V.P Ltd., Romane cannot absolutely guarantee success. Results vary. Please use with physician’s support.