Hypnotherapy Client Intake Form
Please answer the following questions to enhance your session:
How did you find out about me?
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Describe in detail the main reasons you are seeking hypnotherapy.
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Have you done any forms of therapy / healing before? What was your experience overall?
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How do you typically respond when you feel emotionally overwhelmed or triggered? (e.g. shut down, overthink, dissociate, people-please, push through, etc.)
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What area of your life where you are most wanting to experience change?
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For you to consider these sessions a success, what outcome(s) do you need to achieve?
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How will you know your desired outcomes have been achieved: How would you feel? What would be different? What is the evidence?
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What's missing from your life at the moment?
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Have you always achieved what you wanted? If not, what has stood in your way?
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When have you faced a fear in your life?
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What are the ways you have fun, relax and enjoy/reward yourself?
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What are some things you find relaxing? (ocean, forest, your cozy bed, something else…).
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If you have any fears/phobias or images/thoughts that make you uncomfortable, what are they? (heights, closed spaces, elevators, water, something else…).
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Have you ever been diagnosed with, or are you currently experiencing, anything that might affect your ability to enter altered states of consciousness? (e.g. psychosis, unmanaged PTSD, dissociative disorders, substance dependency) This helps me ensure hypnotherapy is safe and supportive for you. *
Do you have any kind of spiritual connection/belief system you would like to share?
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Ayverie pours incredible amounts of time, energy, resources, and care into each of her clients. Are you dedicated to diving into this inner work - in and out of your hypnotherapy sessions to make the most of your healing?
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Are you ready to go on a transformative journey with me?
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Let's go!
No, I'm not ready.
Every session is recorded via zoom and you'll be sent the access link. Sometimes there are special moments that occur during sessions that Ayverie utilizes for educational purposes to bring awareness to alternative healing. Are you open to portions of your session anonymously being used for social media? (the clip will never be used without your final consent if one is selected).
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I am open to clips being used with my additional consent before posting.
No, thank you.
I'm not sure yet, feel free to ask me later.
Informed Consent & Acknowledgment for Hypnotherapy with Ayverie Laroë (Legal name: Lana Pitre). Ayverie’s hypnotherapy is a client-centered, experiential modality that incorporates principles and techniques from Ericksonian hypnosis, Internal Family Systems (parts-based awareness), somatic awareness practices, NLP, inner child exploration, and spiritually informed self-reflection. Sessions are intended to support insight, self-awareness, emotional processing, and personal growth. Hypnotherapy by Ayverie Laroë is not a medical, psychological, or psychiatric treatment, and it does not diagnose, treat, cure, or prevent any medical or mental health condition. Outcomes vary by individual, and no specific results are implied or guaranteed. Practitioner Disclosure & Scope of Practice: I understand that Ayverie Laroë is not a licensed physician, psychologist, psychiatrist, or mental health professional, and that her Hypnotherapy services are not a substitute for medical care, psychotherapy, psychiatric treatment, or professional diagnosis. I acknowledge that Ayverie Laroë does not provide medical, psychological, or psychiatric diagnoses, does not prescribe medication, and does not represent these services as healthcare. I understand that I am responsible for seeking licensed medical or mental health care when appropriate. I further understand that these services are offered for educational, personal development, spiritual exploration, and emotional insight purposes only. Voluntary Participation & Assumption of Risk I affirm that my participation in hypnosis sessions is voluntary and that I may discontinue participation at any time. I understand that hypnosis is a subjective experience and may involve emotional, physical, or psychological sensations, including but not limited to heightened emotional awareness, memory recall, imagery, or bodily sensations. I accept full responsibility for my responses, interpretations, and integration of any experiences arising during or after sessions. I knowingly and voluntarily assume all risks associated with participation. Release of Liability To the fullest extent permitted by law, I hereby release, waive, and discharge Ayverie Laroë from any and all claims, demands, actions, or liability arising from or related to my participation in hypnosis sessions, including but not limited to emotional distress, personal injury, or perceived outcomes. I understand that no guarantees are made regarding results, effectiveness, or personal transformation. Recording & Confidentiality Consent I understand that sessions may be recorded by audio and/or video for documentation, safety, training, or quality assurance purposes. I acknowledge that access to session recordings is at the sole discretion of Ayverie Laroë and is not guaranteed. All recordings will be maintained in confidence unless I provide explicit written consent authorizing the use or sharing of recordings or excerpts. If I consent to the use of recordings for educational or promotional purposes, I understand that once content is shared publicly (by myself or third parties), Ayverie Laroë assumes no responsibility for unauthorized distribution, misuse, or third-party reproduction. Client Certification & Agreement I certify that I am a competent adult of legal age and that I have read, understood, and voluntarily agree to all terms outlined in this document. I affirm that I have had the opportunity to ask questions, seek clarification, and receive satisfactory answers prior to signing. This informed consent and acknowledgment is effective as of the date signed below.
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By checking this box I have read and agree to all of the above.
Is there anything else you wish to share with me?
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