Hypnosis Intake Form

Hypnosis & Past Life Regression Intake Form

Amy's Healing Arts
We are compliant with HIPAA privacy regulations that require healthcare providers and organizations, as well as our business associates, to develop and follow procedures that ensure the confidentiality and security of protected health information.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Gender

MaleFemaleOther
I am over 18 yrs of Age.*

YesNo
Currently under the care of a physician?*

YesNo
Do you have any hearing problems? If so, please explain.*
Have you had hypnosis before?*

YesNo
If so, when was your last hypnosis session?
What was the session for, and what was it like?
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.
Choose the Services you are having today:*

PLRHypnosis
What are your goals for recieving Hypnosis?*

SmokingNail-BitingRelationshipSleepAnxiety/FearPainAlcoholWeight LossPregnancy/ChildbirthStressMotivationMedical IssueDrugsMemory LossMarriage/DivorceAngerStudyingMental HealthAddressing a traumaOther
What are your expectations of today's hypnosis session?*
List any fears/phobias*
List any health problems*
Hypnosis Release Statement

Release statement: I hereby authorize Clifford Aguirre, CHT, and/or Amy Mullett, CHT (Certified Hypno Therapist) to hypnotize me for the purpose outlined in this intake form, including past life regression, and for future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability to relax and my desire to create change myself.

I understand that because the results of my sessions depend greatly upon my own serious participation, we cannot offer any guarantee of the success of my treatment. I am aware, however, that Clifford Aguirre, CHT and/or Amy Mullett, CHT will do everything reasonably in their power to ensure my success. I am also aware that hypnosis is not a replacement for mental health counseling or clinical therapy and that Clifford Aguirre and Amy Mullett are not mental health therapists.
Please sign below if you acknowledge the given information and give your consent to receive the treatment.

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Hypnosis & Past Life Regression Intake Form