Sleep Intake Form

Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Street
City
Zip
Cell Phone
Format: (000) 000-0000.
Employer
Emergency Contact Name
Emergency Contact Phone
How did you hear about Stephanie DeWayne?
What do you find relaxing?
Would you consider yourself a spiritual person?
Please select the reason for your visit

Other, please explain
What previous efforts (if any) have you taken to resolve this issue?
Have you previously been hypnotized?
Have you been under regular Medical or Psychological treatment in the past year?
If yes, please explain
Have you had or are you suffering from: (Check all that apply)
Have you ever been treated for an emotional/behavioral problem?
If yes, please explain
Have you had or do you now suffer from any prolonged illness?
If yes, please explain
Do you smoke marijuana?
If yes, how much per day?
Do you smoke cigarettes?
If yes, how many per day?
If you are currently being treated by a physician or mental health professional, please provide contact information below. If you prefer not to disclose this information, leave this section blank.
Health Professional's Name
Phone
Format: (000) 000-0000.
If you are currently taking prescription medication, those medications may indicate precautions or special circumstances that might be required during your session. **Please list your current medications and the conditions for which they were prescribed.**
Please describe what specifically you are looking to get out of our work together?
Please list three reasons/benefits of this change that we will be making
1.
2.
3.
After making this change, what will be different in you life? What will you be able to do/do differently that you weren't able to do before?
Please share anything else that you think may be helpful for e to know about you, or the reason you want to work with me?
Agreements

Please read and initial each of the following items. If there is an item you do not understand or do not wish to authorize, simply leave it blank. We can discuss any reservations or questions you may have at our initial session.
Scope of Practice The State of Florida does not regulate or license the practice of hypnosis. I, Stephanie DeWayne, am a hypnosis practitioner. I am not a medical or mental health professional and am not licensed to diagnose, prescribe treatment or treat mental or physical disorders. I aid, guide and instruct individuals in using hypnotic and self-hypnotic techniques to achieve goals specified by my clients or their doctors.

My initials typed below indicate that I understand
The State of Florida does not regulate or license the practice of hypnosis. I, Stephanie DeWayne, am a practitioner. I am not a medical or mental health professional and am not licensed to diagnose, treatment or treat mental or physical disorders. I aid, guide and instruct individuals in using hypnotic self hypnotic techniques to achieve goals specified by my clients or their doctors.

My initials typed below indicate that I understand
The use of hypnosis is completely voluntary and should be considered a complementary practice when it is being used to achieve goals that relate directly or indirectly to any physical or mental health concern. When engaging in any complementary practice to treatment you may be receiving from a licensed medical or mental health professional, you should advise those professionals of your intent to utilize hypnosis. It is also advised that you authorize such providers to communicate with me regarding any concerns they may have relevant to the application of hypnosis.

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My practice of hypnosis is client-centered and based entirely on information provided by the client. The efficacy of hypnosis relies on honesty. As a complementary practice, hypnosis relies on your desire for and commitment to bringing about the changes you have specified. This may mean supplementing our sessions with the practice of self-hypnosis (instruction provided), listening to recordings, record-keeping or other homework.

My initials typed below indicate that I understand
As a hypnosis practitioner, I reserve the right to postpone, suspend or terminate our professional if I believe you, the client, would be better served by another professional, need to consult with a medical or mental health professional or if I believe that our work together has otherwise been rendered ineffective.

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The relationship between hypnotist and client does not enjoy protection or privilege in the eyes of the law. voluntarily undertake to keep the purpose, content and records of our meetings confidential unless otherwise by law, either through subpoena or statute. I am legally and/or ethically obligated to report threats of to oneself or others, physical, sexual, emotional, fiduciary abuse or detrimental neglect of children, or other vulnerable individuals. I am also obliged to report crimes, the knowledge of which, would imply or accessory after the fact. (Murder, Kidnapping, Treason for example.)

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Sessions may be audio or video recorded. I always record session if am working with a minor.

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Under certain circumstances it may be necessary for me to respectfully touch your shoulder, hand, wrist, arm or forehead to achieve a beneficial state of hypnosis.

My initials typed below indicate that I understand
I have received a copy of this document and agree to the terms and conditions here-in. I authorize Stephanie DeWayne to hypnotize me for the purposes I have specified and for those I may specify in the future. I understand that my active participation in the hypnosis process is critical and that success depends on my own desire and commitment to bring about change. I understand that Stephanie DeWayne cannot offer a guarantee of success but will do everything within her scope of practice and competence to facilitate my success in achieving my goals.

My initials typed below indicate that I understand
Sessions generally last from 50 to 90 minutes. Payment is expected at the time of service and may be made in cash or by credit card. I do not accept insurance. NO REFUNDS.

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TWENTY FOUR HOUR NOTICE IS REQUIRED FOR ALL CANCELLATIONS. MISSED APPOINTMENTS OR CANCELLATION WITH LESS THAN 24 HOURS NOTICE WILL BE CHARGED $100 FOR THE SESSION.

My initials typed below indicate that I understand
My signature below authorizes Stephanie DeWayne to hypnotize me and I am agreeing to all terms as stated above.
As legal guardian, I authorize Stephanie DeWayne to hypnotize
Name of Minor whose Date of Birth is Date of Birth .
My signature below authorizes Stephanie Dwayne to hypnotize the aforementioned and I agree that sessions will be conducted under supervision of a legal parent or guardian and that all sessions will be recorded.
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