Confidential Client History Form

*Parent/Guardian Signature (Signature is required if the client is under 18 years old)

How did you hear about my Intuitive hypnotherapy and mentoring?*

If referral, who referred you?

If you were referred by a medical professional, do we have your permission to discuss your progress with him/her?

Yes

No

For any pain management sessions, I require a referral. Do you have a referral?

Has anyone ever tried to hypnotize you?

Do you believe that you were hypnotized? If so, why?

Generally, how did it go for you?

Results?

I find it useful to sometimes use a holistic approach (mind-body-spirit) when appropriate. Would you consider yourself a spiritual person?*

Yes

No

Maybe

Are you currently undergoing medical or psychological treatment for the above issue?*

Yes

No

Have you been under a doctor’s care in the past year?*

Yes

No

If “yes” , please give reason

Have you ever been treated for emotional problems?*

Yes

No

If “yes” , are you currently receiving treatment or counseling? Yes No By whom

Have you ever been treated for?*

Heart

Diabetes

Epilepsy

Pain

Are you currently taking any medications?*

Yes

No

Reason for medication?

Have you had any prolonged illness? *

Yes

No

If “yes” , what illness?

Do you have any questions about hypnosis?

Signing this form indicates that you have read the information.*

Yes I understand.

Any appointment changes need to be made two business days in advance. Appointments broken or canceled without the two business days’ notice will be charged for the session.

I have purchased a 4- session Package at the amount of $1295

I have purchased a 10-Session Package at the amount of $2500

I Paid in full at the time of booking the appointment.

Unless a prior agreement has been made of 2 payment of $1250 prior to first session and 5th session

Confidential Client History ForM