Hypnosis Session Information Form

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/Divorced

Date of Birth

Occupation

Emergency Contact (Name / Phone) *This is the person we should contact in the event of a medical emergency

How 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

HypnosisNLPMeditationAcupunctureReikiEFT

Do 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)