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  • Client Intake & Medial History

  • Date*
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  • Date of Birth*
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  • Format: (000) 000-0000.
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  • Have you ever been hypnotized before?*
  • Have you attempted any previous efforts to solve this problem.*
  • Are you currently undergoing medical or psychological treatment for the problem?*
  • Have you been under a physician's care in the past year?*
  • Format: (000) 000-0000.
  • Have you ever been treated for an emotional problem?*
  • If yes, are you currently receiving treatment or counseling?*
  • Have you had any prolonged illness(es)?*
  • Have you ever been treated for? (Check all that apply)*
  • Are you currently taking any medications?*
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  • About your session

  • If you have any questions about your session or hypnosis, please ask! We will explain the hypnotic process in depth prior to your session. If you wear hard contact lens or glasses, please remove them before your session as they inhibit your ability to relax. Hypnosis benefits are proven to be effective, however, there are no guarantees as expectations and results are relative to client responsibility and commitment to succeed. Hypnosis is 80% effective in applications for behavior improvement and stress management necessary to good health and well-being.

     
    Hypnosis is a powerful tool that utilizes the resources of your mind and body to benefit you. Its benefits are relative to your participation, similar to that of a physician who prescribes medication / treatment; it works if you use it.

     
    As a Hypnotherapist, we:

    1.) do not diagnose, treat or cure disease,

    2.) do not assess or evaluate Medical information,

    3.) will determine if we are trained to work with your specific issues and, if not, will refer you to other professionals, and

    4.) are trained and certified in the skills of hypnosis and its beneficial applications.

     

    Our practice is focused on personal growth and empowerment. We encourage you to share your experiences openly while recognizing the choices and opportunities available to you. We understand that life circumstances can be complex, and we're here to support you in exploring them honestly and comfortably so you can achieve the best possible outcome.

  • Rest assured, all client information and all our work together is strictly confidential*


    * Important: Hypnotherapist and client relationship responsibilities include the following statement of understanding: If we are presented with information that may be illegal or threat of harm to you or others, (e.g. suicide, child abuse, etc.), we are legally obligated to report this possibility to the proper authorities.

     
    I understand the hypnosis session I am about to receive is NOT a medical or psychological procedure. I also understand my session may be audio or video taped and I will be notifed prior. Therefore, you hereby have my consent and authorization to record my session. I further understand that during the in person hypnotherapy session, the Hypnotherapist may touch my arm, shoulder, foot or forehead as an anchoring technique for the hypnotic suggestions provided during my session. I hereby give my permission for such touch to take place during the session.

     
    I agree to provide a 48-hour cancellation notice in the event I cannot make my scheduled appointment(s) and agree to pay a $150 cancellation fee if I fail to meet this requirement. 

    I further understand I will be financially responsible for the fee of $150 in the event I fail to arrive (or arrive more than 15 minutes late) for my scheduled appointment(s).

     

    I have read, understand and agree with the above information:

  • *Disclaimer
    Life coaching and hypnotherapy services offered by Jeannine Marzella are designed to support personal growth, stress management, and self-empowerment. These services are not a substitute for medical or psychological treatment. Individuals experiencing severe anxiety, depression, or other mental health concerns should seek guidance from a licensed mental health professional or physician.

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