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Client Intake & Informed Consent Form
Welcome! Please complete this form prior to your first session.

Which session are you booking

Contact Information

Full Name

Date of Birth

Phone Number

Email Address

Emergency Contact (Name & Relationship)

Emergency Contact Phone

Session Goals & Background

What primary goals or positive outcomes are you looking to support through your sessions?

Have you ever experienced hypnosis or guided breathwork before?

Yes

If yes, please briefly describe your experience:

Are you currently under the care of a licensed physician, psychiatrist, or psychotherapist?

Yes

Scope of Practice & Legal Disclosure

"The services I render are held out to the public as non-therapeutic hypnotism, defined as the use of hypnosis to inculcate positive thinking and the capacity for self-hypnosis. I do not represent my services as any form of health care or psychotherapy, and despite research to the contrary, by law I may make no health benefit claims for my services."

Client Acknowledgment & Consent

Please review and check each statement below to confirm your understanding:

Understanding Scope: I understand that the facilitator is not a licensed physician, psychiatrist, or psychotherapist. The sessions offered are for self-improvement, relaxation, and positive mental conditioning, not medical treatment or psychotherapy.

Client Commitment: I understand that hypnosis relies on my own active participation and commitment to self-hypnosis practices, and specific personal results cannot be guaranteed.

Confidentiality: I understand that all information shared during sessions remains strictly confidential, except where disclosure is required by law.

Cancellation Policy: I agree to provide at least 24 hours' notice for any session cancellations or rescheduling requests.

Client Intake & Informed Consent Form
Welcome! Please complete this form prior to your first session.

Which session are you booking

Full Name

Date of Birth

Phone Number

Email Address

Emergency Contact (Name & Relationship)

Emergency Contact Phone

Session Goals & Background

What primary goals or positive outcomes are you looking to support through your sessions?

Have you ever experienced hypnosis or guided breathwork before?

If yes, please briefly describe your experience:

Are you currently under the care of a licensed physician, psychiatrist, or psychotherapist?

Scope of Practice & Legal Disclosure

Client Acknowledgment & Consent

Signature & Authorization

Client Printed Name

Date

Signature

Client Intake & Informed Consent FormWelcome! Please complete this form prior to your first session.

Which session are you booking

Full Name

Date of Birth

Phone Number

Email Address

Emergency Contact (Name & Relationship)

Emergency Contact Phone

Session Goals & Background

What primary goals or positive outcomes are you looking to support through your sessions?

Have you ever experienced hypnosis or guided breathwork before?

If yes, please briefly describe your experience:

Are you currently under the care of a licensed physician, psychiatrist, or psychotherapist?

Scope of Practice & Legal Disclosure

Client Acknowledgment & Consent

Signature & Authorization

Client Printed Name

Date

Signature

Client Intake & Informed Consent Form
Welcome! Please complete this form prior to your first session.