Intake Form

Full Name

Email Address

Phone Number

Are you over 18?

Yes

If you have any physical or mental health diagnoses, are you under the care of someone with the correct license to treat that condition?

Yes, I've got it covered

No, and I need to explain

What, if any, are your spiritual beliefs?

What, if any, is your experience with hypnosis? (optional)

What outcome are we looking forward to today?

How will you feel once you have achieved this outcome?

Confidentiality (optional)

All information relating to this session will be kept confidential and will not be shared except as required by law.

Signature

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law

Parental Signature (if under 18) (optional)

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law