Birthday

Are you currently under medical care relevant to this appointment?

History of: Check all that apply

Sleep Quality

Stress Level

Have you done hypnotherapy before?

I consent to my session being recorded.*

Payment and Cancellation Policy: Payment is due prior to service. Sessions cancelled with at least 24 hours' notice receive a full refund. No-shows or cancellations under 24 hours are non-refundable*

Privacy and Confidentiality Policy: Breakthrough Hypnotherapy complies with confidentiality standards. Your records are stored securely and used only for your care. Your information is not shared without your written consent; except when required by law*

Informed Consent: Hypnotherapy is not a substitute for medical, psychological, or psychiatric care. Participation is voluntary and it is your responsibility to inform of medical or psychological conditions. *

Client Agreement: If client is experiencing a medical emergency, they agree to seek the advice of a qualified healthcare provider immediately. If client is under medical care they will consult their provider before beginning hypnotherapy. *

Voluntary Participation Agreement: Participation in hypnotherapy is voluntary. By engaging in these services you acknowledge and accept full responsibility.*

Date*