Low Country Healing Services, LLC - New Client Intake Form

Low Country Healing Services, LLC - New Client Intake Form

Charleston, SC +1 (916) 217-6386
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method*

EmailPhone
Gender:*

FemaleMale
Birth Date and Time*

MonthDayYear

(If Available) MinutesAM/PM Option
Birth Place (City, State)*

Street Address

Street Address Line 2

CityState/Province

Zip CodeCountry
How did you find me?
Emergency Contact:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Have you ever sought the services of a hypnotherapist?

NoYes (please describe your experience)
Please tell me your primary reason(s) for seeking hypnotherapy (NO reason is wrong or too weird, trust me!).*
How long has the problem or problems been bothering you?
What else have you tried to help relieve these problems?
Do you have epilepsy or have you had a seizure in the last 2 years? (If YES, hypnotherapy is contraindicated unless conducted under medical supervision in a clinical setting)*

YESNO
Are you currently seeing a mental health professional?

YESNO
Have you been diagnosed with a mental illness?

YESNO
Please list all medications, including prescription and non, vitamins, herbs or plant medicines you are taking now or regularly, including an explanation of what you are using the medicine is used to treat.
How many alcoholic drinks do you consume per week?
Number of drinks per week.
Type of alcohol:
Did you ever drink in excess?

NoYes. When did you stop (MM-YYYY)?
Do you exercise regularly?

YesNo
Type of exercise:
Number of times per week/length of sessions:
times per week/length of sessions
Do you sweat?

YesNo
Please describe your approach to diet and nutrition.
How many hours do you typically sleep per night?
How much water do you drink daily?

Does coffee count?Less than 20 ounces20-40 ounces40-60 ouncesAt least half my body weight in ounces
Please select any symptoms you experience now or have experienced within the past 24 months.
Circulatory and respiratory.

DizzinessShortness of breathFaintingCold feet or handsNight sweatsSwollen anklesBlood clotsStrokeHeart conditionAllergiesSinus problemsAsthmaHigh blood pressureLow blood pressureOther (please specify).
Nervous system.

Spinal cord injuryChronic fatigue syndromeNumbness/tinglingTwitching of faceFatigueChronic painSleep disordersUlcersParalysisHerpes/shinglesCerebral palsyEpilepsyMultiple sclerosisMuscular dystrophyParkinson's diseaseOther (please specify).
Other

AnxietyDepressionChronic Pain/FibromyalgiaHeadachesInsomnia/Sleep DisorderArthritis/Musculoskeletal DisorderAddictionOther
Digestive System

Nervous stomachIndigestionConstipationIntestinal gasBloatingDiarrheaDiverticulitisCrohn's DiseaseColitisIrritable bowelFood allergiesOther (please specify).
Other.

Migraine/HeadachesCancerChange of appetiteForgetfulnessConfusionHearing impairmentVisually impairmentPersistent UTIEating disorderDiabetesFibromyalgiaInfectious diseaseOther (please specify).
Low Country Healing Services - New Client Intake Form

Charleston, SC +1 (916) 217-6386
Pursuant to the South Carolina Business and Professions Code, the following disclosure is made by Low Country Services, LLC. about Melanie Topp,Certified Clinical Hypnotherapist.

Low Country Healing Services is a professional practice that provides services that are alternative and complementary to healing arts services licensed by the state.

During an intiial conversation conducted in person, over the phone, or over video chat each prospective client is interviewed, and if it is determined that the services provided by Low Country Healing Services can be of benefit, I will provide services in accordance with my education, training and experience.

I offer the following services:

Clinical Hypnotherapy and Coaching

Hypnotherapy is described as using mental, physical, and emotional relaxation to create a focused state where the therapist can communicate with the client’s subconscious mind to help the client resolve problems and empower them from within.
Coaching is a form of personal development in which an experienced person supports a learner or client in achieving a specific personal or professional goal by providing training and guidance.

These services are not licensed by the state. The services do not include the practice of medicine or psychology or any other licensed healing art since I am not a licensed physician or therapist.

REFUND & CANCELLATION POLICY
All purchased sessions and packages expire 90 days after the date of purchase.

Initial consultations and one-on-one sessions can be cancelled or rescheduled up to twenty-four (24) hours before the session is scheduled to begin without incurring any fees.

No-shows will be charged the full amount of the session without refund.

Due to the nature of the services provided, no refunds will be given at any time, for any reason.

By signing below, I understand that hypnotherapists do not diagnose disease or prescribe medications. I further understand that hypnotherapy is not a substitute for medical attention and examination. I take full responsibility for alerting my practitioner of any physical, mental or emotional changes that occur with my health.

I have read and understand the refund and cancellation policy.

I acknowledge that I have been provided with the above information, have read such and have received a copy of this disclosure.
Please read and verify this mandatory information. Be sure to click all of them.*

I have read and understand the refund and cancellation policy.I understand that hypnotherapists do not diagnose disease or prescribe medications. I further understand that hypnotherapy is not a substitute for medical attention and examination. I take full responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health.I acknowledge that I have been provided with the above information, have read such and have received a copy of this disclosure.
Client Signature

Powered by Jotform SignClear
Date of Signature

MonthDayYear
Type a question
Should be Empty:

Low Country Healing Services, LLC - New Client Intake Form

Low Country Healing Services - New Client Intake Form