Hypnotherapy Intake Form

Name

Email Address

Phone

We will review your responses at the start of your session. What are the top 1 - 3 issues that are bothering you? And why do you think you have them?

What is your desired outcome from this Session? (If I could wave a magic wand and change one thing for you in one session, what would you choose?)

What are the top 1 - 3 changes you’d like to make moving forward in your life? Include the positive end results, such as how you would feel and how your life would look.

From the list below, check all areas that are a concern to you at this time, whether or not related to desired outcome.

Date of Birth

Age

Relationship Status

Please provide name, address, and main contact number of your Primary Physician (Required to Ask)

Do You Give Permission for Me to Contact Your Primary Health Provider?

Yes

No

Session Consent Form for Melissa Boher Jacobson

I understand that Melissa Boher Jacobson is a Clinical Hypnotherapist and a Rapid Transformational Therapist, using methods that include hypnosis, regression, Neurp-Linguistic Programming and other techniques, including Integral Eye Movement Technique, and ADHD Coaching.

I understand that sometimes a single session is all that is required to achieve results, however, some clients may need additional sessions.

I consent that Melissa Boher Jacobson may release information to a specified individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; or if I, as a client, am in eminent danger to myself or others.

I hereby give Melissa Boher Jacobson full permission to hypnotize me and to use Hypnosis and Rapid Transformation Therapy techniques in the knowledge that I do so at my own risk.

I accept that while Hypnosis and RTT has a high success rate, Melissa Boher Jacobson does not guarantee any results and the success of the session(s) depends greatly on my own ability and desire to affect change.

I release Melissa Boher Jacobson from any liability or claims concerning my mental and/or physical well-being during or following the treatment that has been outlined and agreed upon by filling out this form.

I understand that if I am epileptic or suffer from a psychotic illness it is not generally recommended that I undergo hypnotherapy. I hereby agree that by signing this form that I do not currently suffer from these disorders.

I can confirm that I have read the above and understand the process of Hypnotherapy and Life Coaching and accept these terms and conditions.

I have read and agree to the terms above