Confidential Client History ForM

*Parent/Guardian Signature (Signature is required if the client is under 18 years old)
How did you hear about Mind & Body Mastery?*
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?
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?
Reason you are coming for hypnosis
Any previous attempt to address this issue?*
We find it useful to sometimes use a holistic approach (mind-body-spirit) when appropriate. Would you consider yourself a spiritual person?*
Are you currently undergoing medical or psychological treatment for the above issue?*
Have you been under a doctor’s care in the past year?*
If “yes” , please give reason
Have you ever been treated for emotional problems?*
If “yes” , are you currently receiving treatment or counseling? Yes No By whom
Have you ever been treated for?*
Are you currently taking any medications?*
Reason for medication?
Have you had any prolonged illness? *
If “yes” , what illness?
Do you have any questions about hypnosis?
Signing this form indicates that you have read the information.*

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 Five-Session Package at the amount of $875
  • Paid in full at the time of booking the appointment. 
  • Unless a prior agreement has been made of 2 payment of $437.50 prior to first session and 3rd session
Copyright Susan Glavin 2024