Client Information and Release Form

Name*

First NameMiddle NameLast Name

Parent or Legal Guardian Name if under 18 years of age

First NameLast Name

Date of Birth*

MonthDayYear

Age*

Marital Status*

With Whom Do You Share Your Living Quarters? *

Please include names of individuals, approximate age, relationship to you. Listing pets is also encouraged.

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Personal E-mail*

Is this e-mail address a secure place to communicate about our appointments?*

YesNo

Do you wish to receive an Outlook calendar reminder of our appointment directed to this e-mail address?*

YesNo

Mobile Phone*

Area CodePhone Number

Is this mobile phone number a secure place to leave a voicemail or text to communicate about our appointments?*

YesNo

In case of emergency...

Emergency Contact:*

First NameLast Name

Relationship*

Contact Number*

Area CodePhone Number

Please provide information about your past or present major health issues that you feel is essential for me to understand. For example, please indicate if you carry an Epipen and the circumstances that require its use.*

Is there anything else you'd like me to know?

________________________________________________________________________

How did you hear about Pathway to Transformation?*

________________________________________________________________________

Depth Hypnosis Release Form:

Hypnotherapy is a self-regulated, not state-licensed, profession. We are a certified profession, and meet the highest standards set forth by the Association of Depth Hypnosis Practitioners and the Foundation of the Sacred Stream. We practice according to our organization's Code of Ethics and Standards. We have received high quality training through Depth Hypnosis Training Program and the Foundation of the Sacred Stream. We do not do medical diagnosis; nor are we licensed physicians or medical practitioners. We are certified healing arts practitioners – Certified Hypnotists. We provide hypnotherapy services, which give high-quality alternatives for people seeking to overcome many of the challenges of life. We pledge confidentiality.

Recent research has found that memories uncovered during hypnosis, or other forms of induced altered states may not be accurate or even factual. Memory is a constructive and reconstructive process. What is remembered about an event is shaped by what was observed, by conditions prevailing during attempts to remember, and by events occurring between observation and attempted remembering. Memories can be altered, deleted, and created by events that occur during and after the time of encoding, during the period of storage, and during attempts at retrieval.

Therefore, if memories should surface that may be considered grounds for future litigation during the course of hypnotherapy, you may lose your legal right to use this information in a court of law, as it may not be admissible. If certain types of memories begin to surface during any hypnosis session, the session will be discussed so that you may decide whether or not to proceed further with the hypnosis based on your understanding and careful consideration of the above information.

Depth Hypnosis can bring up strong emotions and by signing this document you are indicating that you feel stable enough to handle those emotions. The hypnotherapist is not liable for any pain or emotional distress that may ensue in the course of this work, and it is understood that you will seek medical or psychiatric help as the need arises.

Fees and Procedures:

Fees: My fee is $150 for a fifty-minute session and $225 for a seventy-five minute session unless other arrangements have been made. Payment may be made in the form of a check, cash, card, PayPal or Venmo and is due at the end of each session.

Cancellations: If you are unable to keep a scheduled appointment, kindly give me at least 24 hours notice for a weekday appointment and 48 hours notice for a weekend appointment, or you will be charged the full fee for the time reserved. The same fee will be charged if an appointment is missed without notice.

Phone Calls: When necessary I will be available to consult with you by phone. I do not charge for phone calls under 10 minutes. Calls over 10 minutes will be charged a percentage of my hourly fee.

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I agree to pay the designated fee per session. I am at least 18 years old.

Signature*

New Client Information & Release Form