Follow-Up Short Form

Follow-Up Short Form

Complete your details, relevant history, and acknowledgments for you’re upcoming Hypnotherapy Sessions.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What brings you to into hypnotherapy today? (Describe your main concern or goal)
Was there a specific moment or event that triggered this decision?(Describe a recent experience, conversation, or realization when you said: “Enough. I’m ready to make a change.”):
How does this issue or area of your life currently make you feel emotionally?(Examples: frustrated, stuck, ashamed, anxious, lonely, numb, curious, hopeful, etc.)
If we could wave a magic wand and you had the life, relationship, or confidence you desire—what would that look like? (Feel free to paint a picture. Who are you? What are you doing? How are you showing up in the world?)
What specific behavior, pattern, or situation do you want to focus on changing?(e.g., avoidance of dating, people-pleasing, fear of being seen, sexual shame, lack of confidence, self-sabotage, etc.)
Why do you want this to change?(What's at stake if it doesn’t? What will open up if it does?)
How would your life, relationships, or internal climate benefit from this change?(Think: emotionally, socially, romantically, spiritually, professionally.)
Have you worked with a coach, therapist, or hypnotherapist before? If so, what was helpful or unhelpful about that experience?
What kind of support works best for you?(e.g., gentle encouragement, tough love, structure, creativity, reminders, reflection)
What do you hope will be different after working together?
Is there anything else you’d like me to know about your story, your needs, or your goals?
Are you currently taking medications for seizures or psychiatric conditions?
Disclosure for Hypnotherapy and Coaching Services

This notice is provided in compliance with California Business and Professions Code §§ 2053.5 and 2053.6.

This document is intended to inform you, the client, about the nature of the services I provide and to ensure your understanding and consent. My services are provided as a Certified Clinical Hypnotherapist and Coach.

1. No Medical or Psychological Services: I am not a licensed physician, psychiatrist, psychologist, or medical professional. My services are not intended to diagnose, treat, cure, or prevent any physical or mental disease or condition. You should consult a licensed medical professional for any medical or psychiatric concerns.

2. Alternative and Complementary: The services I provide are considered alternative or complementary to licensed healing arts services. They are not a substitute for medical or psychiatric diagnosis and treatment.

3. Unlicensed Services: The services provided are not licensed by the State of California as "healing arts."

4. Nature of Services: My work involves using hypnotherapy and coaching techniques to facilitate personal growth, improve self-awareness, and help you achieve your goals related to [list specific areas, e.g., stress reduction, habit change, performance enhancement, confidence building]. The methods used may include guided meditation, relaxation techniques, and conversational coaching.

5. Theory of Treatment: The services are based on the theory that the mind, through focused attention and suggestion, can influence behavior and emotional states. The goal is to help you access your subconscious resources to create desired changes and outcomes.

6. My Qualifications: I hold the following educational, training, and professional certifications related to the services I provide: I am a Board Certified Clinical Hypnotherapist by The International Board of Coaches and Practitioners
50 W Broadway, Ste 333 #51903, Salt Lake City, UT 84101 888-731-8375
Your Initial or signature here confrim you have read and understand the Disclosure for Hypnotherapy and Coaching Services
HIPAA Disclaimer: This practice is a private-pay hypnotherapy and coaching practice and is generally not considered a HIPAA-covered entity because it does not engage in HIPAA-covered electronic healthcare transactions. Although HIPAA may not legally apply, your privacy is important. Reasonable administrative, physical, and technical safeguards are used to protect your personal information, and information will only be disclosed when authorized by you or when required by law, such as to comply with mandatory reporting obligations or a lawful court order.
Optional Non-Disclosure Agreement (NDA): If you wish to request an NDA for your sessions, please indicate below.
Client Acknowledgment and Consent

By signing below, I, the client, confirm that I have read and fully understood the information provided in this Disclosure Statement. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.

I acknowledge that I have been given a copy of this signed form and that I am voluntarily consenting to receive hypnotherapy and coaching services under the terms described.

By e-signing below and engaging in my services, you acknowledge that you have read and understood this disclosure.
Signature (Type your full name as your signature)
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: