| Chat4healing.com 480-924-0165 Client information Client name: _____________________________________________________________________ Address: _________________________________________________________________________ City:____________________________________________State/Zip:_________________________ Home Phone: ______________________________________Cell: ___________________________ Work: ____________________________________________Other:__________________________ Consent/Disclaimer I have been interviewed by a Certified Clinical Hypnotherapist and all questions regarding all aspects of hypnotherapy have been answered to my complete satisfaction. I am fully informed of the nature and usefulness of hypnosis. Further, I am aware that no attempt is made to diagnose, prescribe for, and /or treat an infirmity or disease and that no claims of a cure have been made. I have been advised to contact my health care practitioner and/or agency for any changes in medication or health care and to inform them that I am receiving hypnotherapy. I am aware that the purpose of hypnotherapy sessions is to help me to accomplish my goals, and I accept full and complete responsibility for any and every effect, change or result, now or at any future time, resulting from any hypnosis/hypnotherapy sessions or consultations. I hereby agree and request to be hypnotized/guided and acknowledge that hypnosis represents a potentially powerful mental and physical regulating tool. I understand that personal results will vary and that there are no expressed or implied guarantees or warranties of results. All fees must be paid by time of service. A charge of $15.00 will be made on returned checks and $50.00 on missed appointments (WI 24hr notice). Sessions missed within 24 hour notice will be charged. Signature: _______________________________________________________Date:__________________ Chat client form Please print, sign and fax back to 480-654-2430 prior to the session. Thank you |