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Intake Form
Name
Email
Who Did You Book With?
Jayson Rowland, C.Ht CPH
Kenneth Rowland Jr., C.Ht CPH
Date of Birth
Marital Status
Gender
Preferred Pronouns
Orientation
Are you under the care of a doctor?
Yes
No
Current Medical Conditions
Current Medications
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Consent to Contact
I give Hypnosis412 consent to contact my emergency contact only in the event of an actual emergency where my life is in danger or another individual is in my care, and in danger.
Have you ever been diagnosed with any of the following:
Epilepsy
Schizophrenia
Schizo-affective Disorder
Auditory Hallucinations
Visual Hallucinations
Psychosis
None
Do you wear or use any of the following:
Glasses
Contact Lenses
Dentures
Hearing Aide
None
What is your dominant hand?
Left
Right
Ambidextrous
Have you ever attempted hypnosis previously?
Yes
No
If so, what was the result?
I was able to be hypnotized
I did not achieve the hypnotic state
I'm unsure
I haven't tried hypnosis
Using as much detail as possible, why are you seeking hypnotherapy?
Please describe any fears, hesitations, or concerns you have about hypnotherapy
Terms & Conditions
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. All Sessions Are Recorded For Your Safety And The Safety Of Your Hypnosis Professional. These Are Not Available To Anyone Outside Of Hypnosis412. You May Request A Copy Of Your Recorded Session At Any Time.
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