Longmont Hypnosis, LLC   “If You Can Imagine It, You Can Do It!”

 
Name ____________________________
Date of Birth ________     Age _____ 
Email Address ___________________________
Address ______­­­­­­­___________________________ 
City ________________ State ___ Zip ________
Home Phone ____________ 
Business _____________
Cell _____________
Employed by ______________________ Position ____________________
Referred by Dr._______________________ or 
Yellow Pages _____  or 
Friend __________________________
Advertisement____ Internet _____ other_____________________

Are you under the care of a psychologist or psychiatrist? _______________

Current medications _________________________________________

Are you working for or with any state or federal board, licensing agency or
bureau? _____ Explain __________________________________________

Will you be reimbursed for this session by any governmental board, agency
or bureau or individual? ______

What is the nature of the problem that brings you to Longmont Hypnosis?
__________________________________________________________________________________

Have you used hypnosis previously? ______________________________________

I understand that hypnosis is not medical or psychological in nature nor does it take the place of such.

I warrant the above information to be true. I realize that payments are expected at the end of each session. If I do not show up for my scheduled session without calling, I agree to pay for the scheduled hour ($45).

Signature ________________________________ 

Date _______________