Hypnosis & Hypnotherapy

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Hypnosis & Hypnotherapy Client Participation Sign-Up

First Name | Last Name *

Email *

Address *

Phone number *

Work phone number *

Birth Date *

Marital Status *

Occupation *

Have you ever been treated for an emotional problem? If yes, please explain. *

Have you even been treated for: diabetes, heart disorder, or digestive problems? If so, please explain. *

Are you being treated for any illness and under medical supervision? If so, please explain. *

Have you even been hypnotized before? If so, please explain. *

What do you want to accomplish through the use of hypnosis? *

Any previous efforts to solve this problem? Any results? *

How did you hear about me? *

Medical Referral

Relative

Friend

Social Media | Google

Other

Required

Please name the person or source on how you heard about me. *

Do you have any fears or phobia? *

I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnotherapy with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or old illness.

Yes, I understand and agree with the statement above
*

Yes

Required

Preferred Certified Clinical Hypnotherapist to work with:
*

Celia Westbrook, CCHt

Kurt Westbrook, CCHt

Required

Name I like to be called *

Signature | Date *

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