Intake Form for Hypnotherapy

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
Emergency Contact*
I understand that the program of conditioning offered by hypnosis will include an undetermined number of private sessions, depending on my individual needs. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that Gila M. Zak, Master Hypnotist will, to the best of her ability, endeavor to accomplish the objective of my sessions. Cancellations with less than twenty fours hours are subject to a $50 late cancellation fee.
Client Signature*
Entering you name below functions as a "digital signature" and indicates your agreement with the preceding paragraph.
Today's Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.