Life-Changing Hypnosis - Client Release of Information Form

Client Release of Information Form
I, Client Name* authorize Life-Changing Hypnosis and my Hypnotist, Shawna Steilen, to discuss my hypnosis sessions with Name of Professional* .
My hypnotist has my permission to discuss the following items with the above-mentioned professional:

All aspects of the hypnosis sessions
Some aspects of the session, specified as follows: Specifics
Specifics
Client Signature *

Clear
Client Printed Name *
Date *

Month Day Year
Date
Parent/Guardian Signature (If client is a minor)

Clear
Parent/Guardian Printed Name
Date

Month Day Year
Date
Should be Empty: