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 see Pay pal and the release form must be signed , dated and faxed to
480-654-2430.   Missed appointments fee $50.

I want to thank you for choosing Chat4healing to facilitate in your journey.




Signature: _______________________________________________________Date:__________________
Chat client form

Please print, sign and fax back to 480-654-2430 prior to the session. Thank you