Student Intake and Release

Client Details:

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail

example@example.com

Reason seeking Hypnosis:

course, date and location

Do you have any physical, mental or behavioral condition requiring continued treatment by a doctor, psychiatrist or psychologist? If not, please use N/A in the box below. if so, please explain in detail. Please provide a list of medications you are taking. (all info is confidential and for your safety- there are certain medications that are contrary to Hypnosis)

Have you ever been diagnosed with Schizophrenia, Heart Disease, Chronic depression Epilepsy or Bi-Polar disorder? please explain:

How did you hear about us?*

I, First Name Last Nameunderstand that hypnosis is a method for self-exploration and/or behavioral change. This may enable me to search for meaning and understanding and to direct my own personal growth and development.
I further understand that all hypnosis is self-hypnosis.
Since I am in total control of the hypnotic state and session, I can stop a session at any time. The facilitator will use symbols and symbolic language, which I will interpret according to my own belief system. I understand that hypnotherapy uses trance and suggestion to adjust habits of thought, feeling, and behavior.
I choose the goals for hypnotherapy. I also choose the topics of discussion while in the trance state. I understand that hypnotherapy is not offered as a substitute for medical diagnosis and care.
I agree to allow my sessions to be recorded (audio only) for my personal record. I will receive a copy of these recordings. I understand that all information on this form and from any hypnotherapy session is strictly confidential.
I enter into hypnotherapy willingly and out of my own desire for self-exploration and/or behavioral change. Furthermore, I certify that I am requesting hypnotherapy services on my own initiative and realize that Linda Thunberg does not diagnose ailments or prescribe treatment

I acknowledge everything to be true to the best of my knowledge, and I agree not to hold Linda Thunberg liable for any outcomes related to the hypnosis sessions during the session or for any success or challenges I may experience after the session. Signature

Client Intake and Release