Intake Form

Please fill out the intake form below. 
Who referred you/How did you hear about me?*
Please list your current goals for hypnotherapy or coaching*
Fears and phobias can be a concern. What fears or phobias are you aware of?*
Are you concerned about he amount of alcohol you drink?*
Are Loved ones concerned about how much alcohol you drink?*
Are you currently using any narcotics that you would like to address? *
Is stress a major problem?*
Do you feel now or in the past?*
Do you have anxiety or panic attacks when stressed now or in the past? *
Do you have trouble sleeping?*
This questionnaire and your session will be held in the strictest of confidence. Your privacy is important to us.
Thank you for filling out this form.  This information will assist the Hypnotherapy Practitioner to tailor your treatment appropriately.  By signing this health waiver you agree that you have provided this information voluntarily and are undertaking hypnotherapy voluntarily.  You agree to release this Hypnotherapy Practitioner from all liability and will not hold the Hypnotherapy Practitioner responsible in any way for outcomes resulting from methods, instructions and programs used in the course of your treatment.  
The Hypnotherapy Practitioner is not a Medical Practitioner and at no time will your Hypnotherapy Practitioner attempt to diagnose or provide medical or mental health therapy. You affirm that hypnosis is appropriate for you and does not conflict with existing medical or psychiatric treatment. Always seek out and follow the advice of your physician or other professional Medical Practitioner before considering alternative treatment.

Personal information is never shared.

Your appointment is reserved for you. Please allow 24 hours notice for changes or cancellations to your appointment.