Name *

First Name

Last Name

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(###)

###

####

Cell Phone

(###)

###

####

May I leave a message:

Home Phone Number

Cell Phone Number

Email Address

Address

Address 1

Address 2

City

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Marital Status

Married

Single

Divorced

Separated

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It’s complicated

Have you previously been hypnotized?

Yes

No

I agree to become my own best coach and to stop criticizing myself.

I agree

I, understand that the hypnotic methods used by FLOURISH HYPNOSIS are not a substitute for medical or psychiatric treatment. I understand these methods to be a conditioning process, whereby an individual is taught to use their own abilities for their benefit and well – being. With this understanding, I hereby grant FLOURISH HYPNOSIS permission to hypnotize me or the minor child whose name appears at the top of this form. I know my progress is dependent upon my efforts and that there are no guarantees as to the result or progress to be made. I understand that the success of the treatment will be in direct proportion to my commitment to the end result. *

I understand

24 hour notice is required for all cancellations. Missed appointments or cancellation with less than 24 hours notice will be charged for the full amount of the missed session. 50% of the paid missed appointment fee can be applied towards a future session. I understand the policy *

I understand

Date form completed

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