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I, the undersigned, having requested a consultation for hypnotherapy, understand that hypnotherapy is a conditioning process, whereby an individual is taught to use their own abilities, for their own lasting results. I understand that personal results vary. Further, I am aware that hypnotherapy is non-medical, and agree to consult my personal doctor for medical advice and/or treatment.

I realize that missed appointments, without 24 hours notice, will be fully chargeable to me at regular rates.

I understand that I am responsible for the results of my hypnotherapy, and that all payments, for past, current, or future sessions, are non-refundable.

I also understand that all information is strictly confidential.


UNWANTED EMOTIONS


DO YOU HAVE A HISTORY OF:


Habits


PHYSICAL PAIN


PERSONAL


DESIRED EMOTIONS THAT ARE ABSENT


RELATIONSHIPS


PROFESSIONAL


INSOMNIA


WEIGHT