State of Residence
What are your preferred pronouns?
Are you currently under the care of a doctor or other medical professional?
Please list any current health problems, as they may have an effect on the Hypnotic State
Please list any medications, supplements, or other substances that are currently being taken/used. Some medications and drugs can cause an altared effect to Hypnosis. This information will help the Hypnosis Professional in guiding your session.
Emergency Contact Telephone
Have you ever been diagnosed or treated for any form of Epilepsy?
Do you wear corrective lenses?
Yes - Contact Lenses
Yes - Glasses
Have you ever been treated for a Mental Health Concern? (Depression, Anxiety, Schizophrenia, etc. )
Yes - Currently in Treatment
Yes - Previously Treated
In your own words, please describe the issue that lead to seeking hypnosis/hypnotherapy sessions.
Have you ever seen a professional hypnotist/hypnotherapist before? (For this question, we are speaking specifically about undergoing hypnosis - not including those who have seen a stage hypnosis show, videos, etc. You were either hypnotized or attempted to be hypnotized)
Yes - Stage Hypnosis
Yes - Hypnotherapy
If you chose "yes", what was the result?
I was able to experience a hypnotized state
I was not able to achieve a hypnotized state
In your own words, please describe any fears, anxieties, or concerns that you have about being hypnotized. If none, please simply type "none"
Digital Acceptance and Signature
By checking this box, I am giving permission to Hypnosis 412 and Certified Hypnotists associated with the program to use this information to provide me with hypnotism session assistance. I understand that Hypnotism is NOT an alternative to medical or mental health treatment. I will not be asked to stop a medication, diagnosed with any medical/mental disorder, or treated. Hypnosis is used to allow you to access and work within your own subconscious. All hypnosis is self-hypnosis, and I understand that hypnosis is to be used to allow myself to have a better grasp of these issues. Hypnosis is very client-led and thus I will be required to participate in order to get results. I understand that it may take multiple sessions before a noted change is observed. I will not hold Hypnosis 412, it's parent company, or it's Hypnotism Professionals liable for any actions that I take as a result of these sessions. I understand that hypnosis is not "mind control" and that all suggestions will be available for my subconscious and conscious mind to decide if it is best for me. A hypnotist CANNOT make me do anything against my will, to harm myself, or others. I understand that hypnosis is not a covered service for the Health Insurance Portability and Accessibility Act of 1996, though I have an expectation of confidentiality in the same way that one has an expectation of confidentiality in a religious session with a religious leader. I understand that hypnosis is not covered by most insurance companies and thus Hypnosis 412, the Hypnotist, nor any staff member will not submit claims to an insurance agency. All costs associated with hypnotism should be considered "out of pocket" and will not be applied to deductibles.