Disclosure and Consent Form

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Client Information

First Name *
Last Name *
Email Address *
Daytime Phone *
Evening Phone

 

Emergency Contact Information

Contact Name *
Phone Number *
Relationship *

 

Medical Information - Please check all that apply

Sleep Disturbances/Imbalances
Tense/Anxious/Nervous
Headaches/Pain in Neck or Shoulders
Inner Chatter/Can't Turn Off Thoughts
Use Drugs/Alcohol/Cigarettes/Food to Relax
Feel Distracted/Unable to Concentrate
Are you presently in treatment for any condition (Referral may be required) * yes
no
If yes, please describe:
Are you currently taking any medication, prescribed or over-the-counter? * yes
no
If yes, name(s) of substance(s):

 

Additional Information

How did you find out about Full Circle Awareness?
Reason/Goal for Visit
What are your expectations for hypnosis and Reiki
Are you interested in receiving information on upcoming workshops, classes, or specials? * yes
no

 

Disclosure/Consent Agreement

I hereby state that I have no physical or mental conditions that would make it inappropriate or inadvisable to be hypnotized, and I have furnished a referral from my treating physician/ health professional to use hypnosis as an adjunct for my condition(s). Be advised that Renee'€™ does not treat, prescribe for or diagnose any condition. She is a properly trained facilitator of hypnosis and Reiki and is not practicing any other profession that requires a license under the laws and regulations of the State of Florida. Hypnosis is not a substitute for medical or psychological treatment. Hypnosis for sub clinical purposes requires no referral. Renee'€™ only practices therapeutic hypnotherapy within the guidelines of the law and Florida statute 485, which requires a referral and oversight from a licensed practitioner of the healing arts. By signing below, I state that I have read and understand this Disclosure and give my permission to be hypnotized for the purpose of helping me to accomplish my goals I have described above. I further give permission for my sessions to recorded and to be discussed with my physician, if appropriate.

I Agree to the terms set forth in the above agreement. * yes
no
  




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