Hypnosis Session Information Form Instructions Please complete all sections below. This information is used to plan for your first visit and to ensure that the protocol used to help you achieve rapid, positive change is right for you. Full Name *Home Address *Be sure to include street address, city, state and zip code.Best Contact Phone # *Email Address *This is the email address that we should use to communicate with you.Marital Status SingleMarriedWidowed/DivorcedDate of Birth Occupation Emergency Contact (Name / Phone) *This is the person we should contact in the event of a medical emergencyHow did you hear about our services? What is the desired outcome of the hypnosis session(s)? List any current medical or psychological conditions which the hypnotist should be aware *If there are no conditions, then write none.List any current medications your are taking including prescription and herbal *If you are not taking any medications, then write none.Any past experience with the following HypnosisNLPMeditationAcupunctureReikiEFTDo you have any fear or dislike of any of the following? Stairs, escalators, elevatorsWater, oceans, rivers, or lakesDrifting, floating or sinkingBeing touched (head, face, shoulder, arm, knee, etc) VerificationPlease enter any two digits *This box is for spam protection - please leave it blank: