New Client Form

Please take a moment and fill out our new client form, this information will provide us with more information for your session.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Job Title , Employed By

Number of Children

Did someone refer you?

How did you hear about us?

Have you been hypnotized in the past? If yes, by whom?

Reason you are coming in for hypnosis?

Are you currently undergoing medical or psychological treatment for the above issue?

Any previous efforts to solve the issue?

Have you ever been treated for an emotional issue?

Yes

Have you been under a doctor's care in the past year? If yes, please give reason.

If yes, please provide doctors name.

What medications are you currently taking? Reasons for them?

Do you have any questions about hypnosis?

Your answers will be used to help you and facilitate our services to you. Please acknowledge these answers are true.

My answers are true to the best of my knowledge.