Intake Form

Choose Your Hypnosis Professional

What is your Gender? (check as many as you'd like!)

Sexual Orientation

What are your preferred pronouns?

Additional Information

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 Relationship to You

Emergency Contact Telephone

This emergency contact will be used only in the event of a medical or mental health emergency. No information about your goals and hypnosis will be provided to your emergency contact.

I understand that my emergency contact will never be contacted outside of a medical or mental health emergency.

Have you ever been diagnosed or treated for any form of Epilepsy?

Do you wear corrective lenses?

Do you wear dentures?

Have you ever been diagnosed with Psychosis, Schizophrenia, or a personality disorder

If so, which diagnosis did you receive

What is your dominant hand?

Right Left Ambidextrous

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)

If you chose "yes", what was the result?

In your own words, please describe any fears, anxieties, or concerns that you have about being hypnotized. If none, please simply type "none"

In addition to the main concern for your visit, please check any of the following items that you feel may be beneficial to work on with hypnosis.

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.

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.

Hypnosis Intake Form

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