Intake Form for subconscious meditative session Appointment Date * MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Employer Wearing contact lenses? During hypnosis your eyes will be closed for about 45 minutes. If your contacts will cause eye irritation, you may want to bring your lens holder and solution so you can remove them just before hypnosis. Yes No Date of Birth MM DD YYYY Age Primary Goals? Weight Management Smoking/Tabacco Cessation Stress Management Confidence Motivation/Procrastination Relationship Attitude/Outlook Study Skills Fear/Appprehension( explain further below ) Facilitate Wellness ( explain further below ) Self-Esteem/Apprehension ( explain further below ) Change Habits ( explain further below ) Further Explanation? Any previous experience with hypnosis Yes No When? and for what reason? BRIEF MEDICAL HISTORY Current Problems List any medications please Please briefly share anything else that would be helpful to know about you( ie,recent life-changing events such as deaths, divorce, relationships, job changes, health issues, past trauma, accidents, etc.): if other please explain here: FEES & PAYMENT, CANCELLATION POLICY, CONFIENTIALITY, MEDICAL HYPNOSIS, RELEASE STATEMENT, Payment is due in full at the time of service by cash, check, MasterCard, Visa or Discover Card. A $25 fee will be assessed on all returned checks. Your time slot is reserved exclusively for you Please arrive promptly to obtain your full session. A 24-hour cancellation notice is required. If you must cancel or reschedule due to an emergency, please notify us as soon as possible. In the event that you do not arrive for your session and proper prior notice has not been made, you will be charged the entire fee for the session. Thank you for your consideration. We will not release any information to anyone without a written authorization from you, except as provided for by law. Hypnosis is effective in relieving some medical conditions, it will require a signed referral from your doctor or appropriate health care professional to avoid masking symptoms before proper diagnosis and /or medical treatment has been obtained. Of course, non-medical issues (i.e., smoking, weight management, confidence, etc.) will not need a form. I authorize Angelina Marzano, NGH, Certified Consulting Hypnotist, to hypnotize me for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my hypnosis sessions depends greatly on my own ability and desire to affect change in myself. I understand that because the results of my sessions depend greatly upon my own serious participation that she cannot offer any guarantee of the success of my treatment. I am aware, however, that Angelina will do everything in her power to ensure my success. I hereby release Inclusive Healing from any liability. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen hypnosis at this time. PLEASE PRINT YOUR NAME I HAVE READ THIS CLIENT BILL OF RIGHTS AND I FULLY UNDERSTAND WHAT I HAVE READ * YES ELECTRONIC SIGNATURE ( PLEASE PRINT NAME ) DATE ELECTRONICALLY SIGNED MM DD YYYY I understand that, during the hypnosis session, the hypnotist may touch me as part of the introduction or as an anchoring technique. The hypnotist has demonstrated to me such touch and I hereby give my permission for such touch to take place during the session * yes Thank you!