Please complete this form. All information is strictly confidential.

Date

First Name

Last Name

Phone Number (Cell)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Sex

Marital Status

# of Children

Occupation

How did you hear about us?

Are you under a doctor's care?

If so, why?

If so, who is your doctor?

Have you ever been (or are presently being) treated by a psychologist or psychiatrist?

If so, why?

If so, who is your doctor?

Have you ever been hypnotized before?

If so, why?

What do you want to accomplish through the use of hypnosis?

What would you like to accomplish through hypnosis in the future?

If you have any fears or phobias, please describe

Disclaimer: By checking this box I agree that my success with the process of therapy through hypnosis will rest with my persistence with the process and the recommendations of the therapist. I do agree to pay the entire fee for services rendered upon completion of the session unless otherwise agreed upon with the therapist

I agree

Cancellation Policy: By checking this box I agree to pay a $35.00 charge if I do not give a 24-hour notice of cancellation of my appointment, and the full price of the session for a no call/no show.

I agree