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CLIENT HISTORY FORM

Is it OK to...
Do I have permisson to discuss your progress with them?
Has anyone tried to hypnotize you Before?
Any previous attempts to address this issue?
Are you currently undergoing medical or psychological treatment for the above issue?
Have you been under a Doctor’s care in the past year for anything else?
Have you ever had any mental health treatment such as with a counselor, therapist, psychologist or psychiatrist?
Have you ever been treated for...
Are you currently taking any medicatons (including psychotropic medicatons)?
Have you had any prolonged illness?
Other areas you would like to resolve or explore in the future?

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Any appointment changes need to be made 2 business days in advance. Appointments broken or canceled without the 2 business days notice will be charged for the session. If you wear hard contact lenses, please remove them before your session as they may inhibit your ability to relax.

 

AGREEMENT:

Like the practice of medicine, Hypnotherapy and Self-Hypnosis are not absolute sciences. I personally know of no case on record where an individual has been harmed by the use of these methods. I do know of thousands of cases where people of all walks of life have benefited greatly from the use of these methods. As a general practice, it is necessary for everyone taking part in private sessions, classes, workshops and seminars with Hypnolife to sign this release of Liability Agreement.

 

I am of legal age and in consideration of my acceptance as a participant in this Private Hypnotherapy session, Seminar, Workshop, I for myself, my heirs, my executors, administrators and assignees, do hereby release and discharge Debra Colangelo and Hypnolife and any of her employees, her employer or other participants in any of the activities from all claims of damages arising from or growing out of participation in said activities. I agree that any claim of damages or disputes arising from my participation in hypnotherapy sessions, hypnotherapy regression therapies, processing emoJons, neuro-linguistic programming techniques, guided imagery, TAPPING, Mindfulness coaching or events, should it arise, shall be settled by binding arbitration before an extra-judicial arbitration and mediaJon service elected by the parties. I further understand that recordings may be made at any of these events and that Debra Colangelo/Hypnolife and her organization retain the copyright to all of these records.

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CONFIDENTIALITY OF INFORMATION:
Clients have a right to expect that information revealed in sessions not be disclosed without extraordinary justification. The conditions that justify the release of information and, by law must be reported to the appropriate agencies, are the following:
 

  1. Knowledge of child abuse or neglect.

  2. Knowledge of senior citizen abuse or neglect.

  3. A client poses a serious risk of suicide and is an imminent danger to self.

  4. A client poses a threat of imminent danger to another person.

  5. A Judge, by issuance of a court order, may obtain information.

  6. Report to law enforcement authorities knowledge of a felony that has been or is being committed.

  7. In other situations, signed authorization for release of information is required.

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