Name *

Phone Number *
Cell Number *
Email *
Address *
City *
State/Zip Code *
Occupation *
Age *
Date of Birth *
Gender *
Marital Status *
Emergency Contact/Name *
Emergency/Telephone *
Emergency/Address *
How did you hear about us? *
If referral, who referred you?
Have you ever been formally hypnotized? *
For what reason were you hypnotized?
How did it go for you?
Name of previous hypnotist


MAIN GOAL/ISSUE you are coming in now for hypnosis? *
What other methods have you tried to address this issue? *
Which method was most successful? *

In what other areas would you be interested in making improvements? Weight loss? Quitting smoking? Reducing Anxiety? Improving Confidence? Overcoming Fears? Relieving Pain? Improving Sleep? Eliminating Procrastination? Anything else? Please explain.
Are you now or have you ever experienced: nervousness? cigarette smoking? alcohol or drug abuse? recent divorce? trauma or abuse? poor self-esteem? focus issues? abusive home or work situation? sleeplessness? Other? Please explain.


If applicable, please provide all medications currently taking, and reason for taking.
Have you ever been treated for heart disease? diabetes? epilepsy? pain? Please explain. *
Have you ever had any major medical or prolonged illnesses? Please explain. *
Name of Healthcare Provider
Reason for seeing?
May we consult with your healthcare provider?
Have you ever consulted a mental health provider?
Issue? Diagnosis?
Name and location of Mental Health Provider
Do we have permission to consult with your mental health care provider?


What do you do for fun? *
List your favorite places *
What is your favorite color? *
Do you follow any spiritual practices? *
Do you have any fears/phobias? *
What are your hobbies? *
Comments/Extra Space


I understand that hypnosis is not a substitute for medical care or medication, and is not meant to treat any diagnosis or disease. It is intended to provide information, education and mental conditioning so that you can feel better and be more effective. *
I understand that the practice of hypnosis is not an exact science and that Hypnosis Columbia LLC cannot offer a guarantee of the success of my treatment, nor are refunds given for services rendered. I am aware, however, that Hypnosis Columbia LLC will do everything in its power to ensure my success. *
I am encouraged to advise my doctor and/or seek the advice of a licensed health care provider, should I choose, with regard to treating me for specific medical or psychological issues. *
I understand that audio and video recordings may be made during sessions and that Hypnosis Columbia LLC retains rights to these recordings. By placing my full name below, I am stating that I have read this form and understand all of its contents. *
I hereby authorize Hypnosis Columbia LLC to hypnotize me for the purpose described herein and for future purposes that I may request. I fully understand that the success of my hypnosis sessions depends greatly on my own desire and willingness to create change in myself. *
I do hereby release and discharge Hypnosis Columbia LLC and its associates from all claims or damages or responsibility from alleged damages arising from or growing out of my participation in hypnosis or the use of other tools and techniques employed by Hypnosis Columbia LLC. *
Electronic Signature -- By placing my full name below, I am stating that I have read this form and understand all of its contents.