Intake Form

All fields must be filled out.

Date

Referred by:

What Issues Bring You Here For Hypnotherapy?

Goal for Hypnotherapy?

Name

Address

Cell Phone

Email Address

Date of Birth & Where?

Education – Where & What Field?

Occupation

Relationship Status

Parents Living?Parents Living?YesNo

Parents Together?Parents Together?YesNo

Siblings?

In Therapy Now? In Therapy Now? YesNo

Have You Been in Therapy?Have You Been in Therapy?YesNo

Or In Hypnotherapy?Or In Hypnotherapy?YesNo

Medications?

Kay B. Heatherly, Certified Hypnotherapist

Consulting Agreement:

Hypnotherapist:

I agree to the best of my abilities to help you make the changes you seek and to treat you with care and respect. I am fully committed to the time that I have scheduled for you. I agree to give you my undivided attention and professional assistance during our scheduled consultation, and I agree to strict confidentiality.

I am professionally committed to using my training and skills to assist you in mobilizing your own resources to achieve the results you seek. I do not represent myself to be qualified as a psychologist or marital / family counselor.

Kay B. Heatherly

Client:

I realize that my success depends on my own commitment to improving the situation that brings me here. I acknowledge that the hypnotherapists is not diagnosing, prescribing for, or treating any physical or mental ailments, and that she has made no representations to me that she is qualified to do so.

I release the hypnotherapist from any liability regarding my hypnotherapy session. Any conclusions I draw from my session are mine and I take full responsibility. I understand that these sessions are not psychotherapy, but are a therapeutic alternative aimed at creating positive change in my life.

I acknowledge and understand that the sessions do not constitute a replacement for psychotherapy or marital / family counseling, and I take full responsibility for commencing and / or continuing such treatment where the same is necessary or appropriate. I realize that in hypnosis, it’s not the depth of the trance that matters for positive change… light-to-medium trances are proven to be highly effective.

I agree to be on time for appointments and to pay for any missed appointments not cancelled at least 48 hours in advance. (If there is an emergency and the session can be scheduled within the week, there will be no charge for the missed appointment.)

I agree to participate in a minimum of 3 sessions, knowing that this is a process. At the end of the 3^rd session, if I feel more sessions are necessary, I understand they are available to me.

Client’s Name:

Date:

Kay B. Heatherly, Certified Hypnotherapist

DISCLOSURE

Kay Heatherly is providing professional services for avocational or vocational self-improvement of Client which does not include therapy for emotional or mental disorders. She is not a licensed physician. These services provided are alternative or complementary to the healing arts services that are licensed by the State of California. Hypnotherapists, and the services they provide, are not licensed by the State of California.

I, Kay Heatherly, have acquired the following education, training experience, and qualifications regarding the services to be provided:
Certification by the Palo Alto School of Hypnotherapy and the National Guild of Hypnotherapists.

I, the undersigned Client, acknowledge that I have been advised of the foregoing in a language that I understand, that I have been given a copy of this “Client Disclosure” form, and that I understand a copy shall be maintained by Kay Heatherly for a period of three years.

Dated

Client's Signature

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