Hypnosis & Hypnotherapy
Hypnosis & Hypnotherapy Client Participation Sign-Up
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First Name | Last Name *
Email *
Address *
Phone number *
Work phone number *
Birth Date *
Marital Status *
Occupation *
Have you ever been treated for an emotional problem? If yes, please explain. *
Have you even been treated for: diabetes, heart disorder, or digestive problems? If so, please explain. *
Are you being treated for any illness and under medical supervision? If so, please explain. *
Have you even been hypnotized before? If so, please explain. *
What do you want to accomplish through the use of hypnosis? *
Any previous efforts to solve this problem? Any results? *
How did you hear about me? *
Please name the person or source on how you heard about me. *
Do you have any fears or phobia? *
I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or old illness.
Yes, I understand and agree with the statement above
Preferred Certified Clinical Hypnotherapist to work with:
Name I like to be called *
Signature | Date *
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