New Customer 100% CONFIDENTIAL History Form & Waiver
Please fill out the following †new customer form so you can bring it to our first session. This will allow us to maximize your time during our session.
If it is your first session please also read The Truth About Hypnosis, located on our website before you come in. Even if you have been hypnotized before, we cannot be held accountable for the ineffectiveness of the hypnosis you received before us. :)
Because we are often booked out a week to a week and a half we require advanced payment via or credit cards over the phone to book your session.
Cancellations, Missed Appointments and Rescheduling Appointments Policy
48-hour cancellation notice required. We require two working days before the day of the appointment. For example, if the appointment is on Thursday, in order to not be charged for an appointment, we need to be notified of the change no later than Tuesday. No Exceptions.
Clients making cancellations, missing appointments or rescheduling on the same day as the appointment for ANY reason, will be charged for the time scheduled for that day, because we will be unable to utilize that time to schedule in another client upon such short notice. No Exceptions.
Because you are paying for a time spot (often being booked between other sessions), you are paying for our time. Hence, this is being done to ensure that our appointment times are being best utilized. Many clients are needing to wait 1-2 weeks to come in. If we are given enough advance notice, then we are able to schedule our clients efficiently.
Thank you for understanding and we look forward to serving you.
Confidential Salt Lake City Hypnosis Center History Form & Waiver
Address ________________________________________City, State ______________Zip_____________
Marital Status ______ # of Children ____ Gender ____ Employer _________________________________
Phone _____________________DOB ________E-Mail _________________________________________
How did you hear about me? ______________________________________________________________
Prior hypnosis experience? Please explain? ___________________________________________________
What was the problem? Basically, what specifically have you come here to change? _______________
Any previous efforts to solve the problem? Yes___ No___ Results? _______________________________
What is the impact on your whole life of having this problem?† Including what is costing you spiritually,
emotionally, financially, physically, and in your relationships to having this problem?
What would have been your likely future if things donít change for you?
If you take a look, what possible way of being is missing, the presence of which would make a difference?
What might you feel we need to do for you to permanently cure this issue?
What is one of the BEST experiences of your entire life, a time you felt confident, proud, loved and on top of the world?
Benefits of making the change you want (Please list at least 7)
Check as many of the following as it applies to you, and fill in the blank space if appropriate.
____I often feel that I should be punished for something I once did.
____I know of a past experience or relationship that could be causing this problem.
____I am aware of an internal conflict that may be causing part (or all) of my problem.
____If I get better, I stand to lose _______________________________________________.
____If I wasnít so much like ____________________________, Iíd be much happier.
I find it useful once in a while (not mandatory) to take a holistic approach to healing (Mind+Body+Spirit) when appropriate.† Would you consider yourself a spiritual person?† Please explain? __________________
Medical Information: Are you pregnant, or ever been diagnosed as a diabetic, diagnosed with asthma, have a heart condition, or diagnosed with epilepsy?
(If yes to any please circle which one(s) and explain) ___________________________________________
Have you been under a doctorís care this past year? Yes___ No___ Are you currently receiving counseling
or treatment? Yes___ No___ Have you any prolonged illness? Yes___ No___ Have you ever been
diagnosed with emotional problems or experienced serious trauma or abuse? Yes___ No___
If yes to any of the above please explain details? ______________________________________________
Medications currently taking and why? ______________________________________________________
Please be as detailed as possible. Other issues (may or may not be related)?
___ Anxiety/Stress††††††††††††††††††††††††††††† ___ Attitude†††††††††††††††††††††††††††††††††††††††† ___Bad Habits? _______________
___Poor Exercise Habits††††††††††††††††††† ___Fatigue††††††††††††††††††††††††††††††††††††††††††† ___Fear of Failure
___Focus††††††††††††††††††††††††††††††††††††††††††††† ___Forgiveness/Anger††††††††††††††††††††††† ___Grief Issues/PTSD
___Headaches/Migraines††††††††††††††††† ___Irrational Fears (Phobias)? ________________________________
___Nail biting†††††††††††††††††††††††††††††††††††††† ___Pain Relief†††††††††††††††††††††††††††††††††††† ___Emotional Eating
___Procrastination††††††††††††††††††††††††††††† ___Relationship Issues††††††††††††††††††††† ___Road Rage
___Self Discipline††††††††††††††††††††††††††††††† ___Self Esteem (Low)††††††††††††††††††††††† ___Self Sabotage
___Skin Problems†††††††††††††††††††††††††††††† ___Social Anxiety (Shyness)††††††††††† ___Sexual Issues? _____________
___Stuttering††††††††††††††††††††††††††††††††††††††† ___Smoking†††††††††††††††††††††††††††††††††††††††† ___Tension
___Test Anxiety††††††††††††††††††††††††††††††††† ___Tiredness††††††††††††††††††††††††††††††††††††††† ___Weight Loss (Release)
___Worry††††††††††††††††††††††††††††††††††††††††††††† ___Worthlessness††††††††††††††††††††††††††††††† ___Other? (Please explain)Ö
TERMS AND CONDITIONS:† I hereby certify that the above information is correct. I understand that I am aware that I am participating in hypnosis, I understand what it means to be hypnotized, I understand, and act on my own free will, and I cannot be asked to do anything against my will. By signing my name I understand that SLCHC does not prescribe drugs, diagnose medical conditions or provide treatment for such conditions, and results are in no way guaranteed.† We are not a licensed mental health facility. Code: V66.20
I understand SLCHC appointment policy requires 2 working days to reschedule or cancel an appointment (even if emergencies) or I will be charged for the session.† I am willing to do whatever it takes through behavior change processes and hypnosis to get the change I came to make.
I agree to have Slc Hypnosis Center have the right to record my sessions. Many clients have felt most comfortable knowing their hypnosis sessions are recorded while they are doing hypnosis. These recordings are the sole property of Slc Hypnosis Center and only for legal purposes would they ever be used. Aside from that, these are still 100% confidential and are not shared with anyone outside of Slc Hypnosis Center. These are available for you to purchase for a nominal fee of $30 each session.
Signature of Participant or Legal Guardian ________________________Date______________