In Take Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name *FirstLastDay of Birth -Age *Email Address *Have you ever had Hypnosis before? *YesNoRelevant Medical History *Do you currently experience or have a history of any of the following ( check all that apply ) *AnxietyDepressionPTSD or traumaInsomniaSubstance useNeurological condition ( e.g , epilepsy )OtherAre you currently under medical or psychological care? If yes please describe. *Current Medications and Supplements *Lifestyle Habits ( sleep, exercise, diet, smoking, alcohol Other ) * Medications Emergency Birth What do you hope to achieve through hypnosis session ?Emergency Contact Name *Phone NumberRelationship to Emergency ContactConsent and Agreement (Please read and type your full name to consent) * I understand that hypnosis is a complementary wellness method and not a substitute for medical or psychological condition. I affirm that all information I have provide is true and accurate to the best of my knowledge I Give my informed consent to participate in hypnosis sessions. ( By typing your name, you agree to participate in hypnosis and acknowledge the terms provided by the hypnotist)SignatureDateSubmit
