APPLICATION, PERSONAL DATA RECORD

Client Questionnaire This questionnaire will help me to identify any contraindications to our sessions. Please answer the questions as accurately as you can.

All personal data is for the Practitioners use only. If I need to contact your GP/Consultant it will be with your written consent.

(Please put as much information as you can and use more pages if required) 

WOLF CREEK WELLNESS

LORI DONNELLY HYPNOTHERAPY 

In recognition that millions of Californians receive a substantial volume of healthcare services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code. The purpose of a program of hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state. Ahypnotherapist is not a licensed physician or psychologist and hypnotherapy services are not licensed by the State ofCalifornia. Services are non-diagnostic and do not include the practice of medicine. neither should they be considered as a substitute for licensed medical or psychological services or procedures. Hypnotherapists who assist clients with weight loss and/or other health and fitness goals may provide general nutritional advice and/or recommend published books, food guides and health and fitness publications. This is not a substitute for medical advice and you are advised to seek your Doctor's approval before making any medical/health/ lifestyle changes. Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors. emotions, attitudes and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives. Services consist of a program of conditioning, including an undetermined number of private sessions, depending on the client's individual needs. The hypnotist will to the best of his or her ability endeavor to accomplish the objectives of the client's sessions. While hypnosis may be an effective technique for many purposes. the effectiveness may vary from individual to individual, and no specific results or progress can be promisedor guaranteed. The feelings and experiences one has in the hypnotic state can vary from individual to individual. Many people remain completely aware of everything that is going on while in hypnosis. Some individuals experience a hyper- awareness where sensations are perceived enriched and vivid. The ability to visualize or imagine is often enhanced. A feeling of deep relaxation is common and some people describe the hypnotic state as an escape from physical tension and emotional stress, while remaining completely alert. The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client. While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy. I have received a copy of this disclosure and understand the information described above. / have also read the accompanying document which is a biography of the Hypnotherapists education, training. experience and other qualifications regarding the services to be provided. Client Name or Guardian (please print):

WOLF CREEK WELLNESS

LORI DONNELLY HYPNOTHERAPY 

SUBJECT: SELF-IMPROVEMENT PROGRAM

I, the undersigned, acknowledge that I understand and agree to the following:

1agree to pay you Lori Donnelly WCW. a fee of $495.00 for the first 2 hour and session 350.00 per follow up sessions unless discount packages are purchased See below (home or facility visit special pricing) I also agree to pay you for your services, in full, on or prior to the date of each session. Iagree to give you 24 hours notice for all cancellations or changes of scheduled appointments.I understand, that missing a scheduled appointment without prior cancellation or canceling with less than 24 hours notice. may be charged to me at the current full rate. I understand that the program of conditioning offered by you will include an undetermined number of private sessions, depending on my individual needs. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908 I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of my sessions.

FEES

HYPNOTHERAPY. IEMT. NLP & BRAIN HEALTH FEES & packages:

1st Session is (2) hours at $495 In Office,Phone, ZOOM,  ($695 Home or Facility) Additional A la carte sessions Office,Phone, ZOOM are $350,  Addition private in Home or facility $550 plus travel expenses please enquirer for out of state or country fees and packages.

Discounted Packages: Must be prepaid in full, completed within 6 months and cannot be transferred.

Included first 2 hour session. + In Office, Phone, ZOOM Private Home or Facility Visit PKG 5 Sessions approximately 6 hrs (w/first session ) $1495 $495.00 first session add 4 more sessions $1000.00

8 sessions $1800.00.

10 sessions $2000.00

At any time you can upgrade your sessions. PayPal, Venmo, cash, credit card or Zelle Packages can be purchased at the end of the first session if desired

I provide sessions in person/office, by phone, Zoom or in the comfort of your own home or facility. I fwarranted You may receive a FREE MP3 Recording of your sessions so you can listen to the hypnotic suggestions at home for faster results. It is important to dress comfortably and eat a small meal or snack a couple of hours before your appointment. Drink lots of water all day. Please make sure you have a quiet comfortable location that you can set up your phone or computer for our Zoom session.

Your 1st session may include some or all of the following: Adetailed intake of your issue(s) Explanation the Conscious/Subconscious Mind Left/Right Brain Suggestibility Testing for Hypnotic Depth Setting goals & addressing Self-Sabotage Releasing Procrastination & Resistance Desensitization of Habits, Patterns and Limiting Beliefs Hypnotic Inductions & Deepening Techniques NLP (Neuro-Linguistic programming) Anchoring for Positive Outcomes Guided Imagery and Self Hypnosis Techniques IEMT (Integral Eye Movement Therapy) Brain Health coaching MP3 recording I require a 24-hour notice for any changes to your scheduled appointment time. Please arrive 10 minutes early to your first session to get familiar with the location. If you are running late, text me immediately at (805)444-7379 I look forward to assisting you in achieving your goals.

THE MIND BAR Hypnotherapy                                                                           20969 Ventura Bivd Suite #219 Woodland Hills, CA 91364

Wolf Creek Wellness Hypnotherapy (Camarillo area)                                         11600 Santa Rosa RD Santa Rosa Valley, CA 93012

Hypnotically Connected Lori Donnelly C.HT wolfcreekwellness.us wolfcreekwellnesss@yahoo.com 805-444-7379