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Downloadable intake form link - here. Below see intake form as well.
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TRANS-HYPNOTHERAPY
DESIREE HOLMES SCHERINI, BCH,CHt,LBLt, CRMT
CERTIFIED TRANSPERSONAL CLINICAL HYPNOTHERAPIST AND NLP LIFE COACH
TRANSHYPNOTHERAPY@GMAIL.COM OFFICE 202.203.0725 CELL 443.694.5618
CLIENT INTAKE, RELEASE, DISCLAIMER: ~ Name:_________________________________________Birthdate:______________
Address______________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________
Telephone:____________________________
Email:_____________________________________________________________
Reason for seeking Services: ________________________________________________
_________________________________________________________________Current Medications and Drugs: ______________________________________________________________________________________________________________________________________________ (Continue on back of sheet, if necessary)
Have you been diagnosed with any of the following? Yes or no for each, please. ____ Schizophrenia _____Chronic Depression _______Bi-polar ____ Heart Disease______ Epilepsy
If you have any of the above conditions, we must have a doctor’s written referral to proceed with your hypnotherapy session. Do you have any mental or behavioral condition requiring continued treatment by a psychiatrist or psychologist? If yes, please explain as these may have a bearing on our work together
:_________________________________________________________________________________________________________________________________________________________________________________________________________________ Informed Consent: I, , understand that hypnosis is a method for self-exploration and/or behavioral change. This may enable me to search for meaning and understanding and to direct my own personal growth and development. I further understand that all hypnosis is self hypnosis. Since I am in total control of the hypnotic state and session, I can stop a session at any time. The facilitator will use symbols and symbolic language, which I will interpret according to my own belief system. I understand that hypnotherapy and nuero-linguistic Programming may use trance and suggestion to adjust habits of thought, feeling, and behavior. I choose the goals for hypnotherapy and life coaching. I also choose the topics of discussion while in a trance state or session. I understand that hypnotherapy is not offered as a substitute for medical diagnosis and care. I agree to allow my sessions to be recorded for my personal record if desired. I understand that all information on this form and from any hypnotherapy/life coaching session is strictly confidential. I enter into hypnotherapy and Life Coaching willingly and out of my own desire for self-exploration and/or behavioral change. Furthermore, I certify that I am requesting hypnotherapy or life coaching services on my own initiative and realize that (practitioner) does not diagnose ailments or prescribe treatments.
Signature _________________________________________________________________ date _________________________________________________________________
DESIREE HOLMES SCHERINI, BCH,CHt,LBLt, CRMT
CERTIFIED TRANSPERSONAL CLINICAL HYPNOTHERAPIST AND NLP LIFE COACH
TRANSHYPNOTHERAPY@GMAIL.COM OFFICE 202.203.0725 CELL 443.694.5618
CLIENT INTAKE, RELEASE, DISCLAIMER: ~ Name:_________________________________________Birthdate:______________
Address______________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________
Telephone:____________________________
Email:_____________________________________________________________
Reason for seeking Services: ________________________________________________
_________________________________________________________________Current Medications and Drugs: ______________________________________________________________________________________________________________________________________________ (Continue on back of sheet, if necessary)
Have you been diagnosed with any of the following? Yes or no for each, please. ____ Schizophrenia _____Chronic Depression _______Bi-polar ____ Heart Disease______ Epilepsy
If you have any of the above conditions, we must have a doctor’s written referral to proceed with your hypnotherapy session. Do you have any mental or behavioral condition requiring continued treatment by a psychiatrist or psychologist? If yes, please explain as these may have a bearing on our work together
:_________________________________________________________________________________________________________________________________________________________________________________________________________________ Informed Consent: I, , understand that hypnosis is a method for self-exploration and/or behavioral change. This may enable me to search for meaning and understanding and to direct my own personal growth and development. I further understand that all hypnosis is self hypnosis. Since I am in total control of the hypnotic state and session, I can stop a session at any time. The facilitator will use symbols and symbolic language, which I will interpret according to my own belief system. I understand that hypnotherapy and nuero-linguistic Programming may use trance and suggestion to adjust habits of thought, feeling, and behavior. I choose the goals for hypnotherapy and life coaching. I also choose the topics of discussion while in a trance state or session. I understand that hypnotherapy is not offered as a substitute for medical diagnosis and care. I agree to allow my sessions to be recorded for my personal record if desired. I understand that all information on this form and from any hypnotherapy/life coaching session is strictly confidential. I enter into hypnotherapy and Life Coaching willingly and out of my own desire for self-exploration and/or behavioral change. Furthermore, I certify that I am requesting hypnotherapy or life coaching services on my own initiative and realize that (practitioner) does not diagnose ailments or prescribe treatments.
Signature _________________________________________________________________ date _________________________________________________________________