Advanced Hypnosis

Client History Form

Please, fill out what applies to you

Please provide your name:

Name
Age
Sex	Male Female

Please provide your address:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
Cell Phone
E-mail

Marital Status:

Single Married Divorced Common Law Other

Number of children?

Occupation.

Spouses Name.

Reason for coming for Hypnosis/Guided Imagery?

 

 

Medical History

Any previous efforts to solve the above problem?

Are you presently undergoing Medical or Psychological treatment for the above problem?

Yes No

How long have you been receiving treatment?

What is your physicians name?

Are you currently on any medication for the above problem or any other condition?

Yes No

Please specify what medication you are taking?

What are the affects of the medication?

Please indicate where you found the information for my services?

 

Important! Please Read the following

Please remove contact lenses before the session. They may inhibit your ability to completely relax. Please use the bathroom before the session as that may also inhibit relaxation.

 

Please read the statement and if you agree please sign the bottom signature section.

 

I hereby authorize, Wally Muller, to hypnotize or use guided imagery with me for the purposes outlined in (reasons for coming for hypnosis/guided imagery) and for any future purposes I request.

 

I understand that the results of my hypnosis/guided imagery depend greatly on my own ability to relax and the desire to create change.

 

I understand that the result(s) achieved from my session(s) depends greatly on my serious participation.

 

I understand that hypnosis/guided imagery is not a medical or psychological procedure.

 

I am aware and trust that Wally Muller will do everything reasonable in his power to ensure my success.

 

I understand that the hypnosis/guided imagery sessions will be audio taped for any follow up session's and continuity and all sessions are completely confidential.

 

Wally Muller does not offer any guaranties as to the success of my sessions(s).

Date: