confidential client history form & registration
TRANSCRIPT
CONFIDENTIALCLIENTHISTORYFORM®ISTRATION
PrintFullName_________________________________________________________________________________ Date___________________________
HomePhone____________________________CellPhone____________________________Email________________________________________________
Address______________________________________________________Apt_______City____________________________State_______Zip_____________
DateofBirth ___________________________Age_________Sexo M oFOccupation______________________________________________________
Doyouenjoyyourjob?oYesoNoDoyouconsideryourselftobestressed?oYesoNo
Status:MinoroSingleoMarriedoPartneredoInaRelationshipoDivorcedoSeparatedoWidowedo
Intheeventofanemergency,whomshouldwecontact?____________________________________Relation_______________________________
HomePhone_________________________________WorkPhone________________________________CellPhone________________________________
Howdidyouhearaboutus?
Internet/Websiteo Yelpo PsychologyTodayo Mailero Brochureo BeLiveTVo YouTubeo Radioo
Thumbtacko Referralo Ifso,whoreferredyou?_________________________________________________________________________________
Pleasecircleyourdominanthand
Doyouconsideryourselftobevisual,auditory(hearing/listening)orkinesthetic(touchinganddoing)?Pleaseratebelowonascaleof1-10.1=least.10=most
Visual
Auditory
Kinesthetic
Whatmakesyouhappy?Listthefirst3thingsthatcometomind:
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
HEMISPHERE HYPNOTHERAPY www.hemispherehypnotherapy.com
321A Boston Post Road, Sudbury, MA 01776
(508) 340-9122
L R
MedicalHistory
Ifyouwerereferredbyamedicalprofessional,maywediscussyourprogresswithhim/her?oYesoNooN/A
GeneralPractitioner/MedicalDoctor_____________________________________________________Phone#____________________________________
Specialist/s__________________________________________________________________________________Phone#____________________________________
Areyoucurrentlyundergoingmedicalorpsychologicaltreatment?oYesoNoWhy?__________________________________________
Haveyoubeenunderadoctor’scareinthepastyear?oYesoNoIf“yes”,pleasegivereason_________________________________
Haveyoueverbeentreatedforemotionalproblems?oYesoNo
If“yes”above,areyoucurrentlyreceivingtreatmentorcounseling?oYesoNo
Bywhom?_______________________________________________________Phone#__________________________________
Haveyoueverbeentreatedfor:Hearto Strokeo Diabeteso Epilepsyo Paino
Areyoucurrentlytakinganymedications?oYesoNoReason?__________________________________________________________________
Pleaselistmedications:____________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Haveyouhadanyprolongedillness?oYesoNoIf“yes”,whatillness?___________________________________________________________
ForWomen:Areyoupregnant?oYesoNoIf“yes”,howmanyweeks?_________________________________________________________
Doyoudoyoga? oYesoNo
Doyoumeditate? oYesoNo
Doyouconsideryourselfaspiritualperson?oYesoNo
Doyouconsideryourselfanintuitiveperson?oYesoNo
Doyouconsideryourselftogenerallyleadwithyour“heart,”your“mind,”orboth?__________________________________________________
Pleasefeelfreetofillintheboxanywayyouchoose,orleaveitblank.
Hypnotherapy
Pleasestatethereason/swhyyouareseekinghypnotherapyatthistime?
_______________________________________________________________________________________________________________________________________________
Pleaserateandcircleyourcurrentlevelofmotivationtochangeonascaleof0-10.(Zerobeingthelowest,10beingthehighest.)
01 2 3 4 5 6 7 8 9 10
Iflessthana10above,whatdoyoubelieveisblocking/stoppingyoufrombeingfully“motivated”tochange?
_____________________________________________________________________________
Haveyoubeenhypnotizedbefore?oYesoNoReason_____________________________________________________________________________
Bywhom?___________________________________________________________________________________________________________________________________
IfYES:Whatdidyoulikebestaboutit?____________________________________________________________________________________________________
Whatdidyoulikeleastaboutit?____________________________________________________________________________________________________
PleaseCHECKanyofthefollowingsymptomsandconditionsyoumaybecurrentlyexperiencingorhavehadinthepast.Alsocheckothersituationsinyourlifethatyou’dliketoresolve/improve.
o AcidRefluxo ADD/ADHDo AlcoholAbuseo AngerManagemento Anorexiao Anxietyo Asthmao Auto-immunediseaseo BadHabitso Bedwettingo BirthingPreparationo Bulimiao CancerRemissionTherapyo ChemotherapySideEffectso ChildhoodAbuseo ChronicFatigueSyndromeo ChronicStresso Claustrophobiao Co-dependencyo Colitiso CompulsiveGamblingo Concentrationo Couples“Counseling”o Crohn’sDiseaseo Depressiono DivorceIssueso Emetophobia(fearofvomiting)o ExamAnxietyo Fear__________________________
o FearofDoctors/Dentistso Fertilityo Fibromyalgiao Griefo Headacheso IBS/IrritableBowelSyndromeo Insomniao IntimacyIssueso Memory(Recall)o Memory(Retention)o MenopausalSymptomso MenstrualProblemso Migraineso Misophoniao Motivationo NailBitingo OCDo Pain(ChronicorAcute)o PanicAttackso Perfectionismo Phobia__________________________o Pickingo Procrastinationo PTSDo PublicSpeakingo RecoveringMemorieso Relationshipso Relaxationo Salesmanship
o SelfConfidenceo Self-Mutilationo SexualDysfunctiono SexualTraumao SleepIssueso SmokingCessationo Speech/Stutteringo SportsPerformanceo StageFrighto StressManagemento Strokeo SubstanceAbuseo SurgicalAnesthesiao TeethGrinding(Bruxism)o TimeManagemento “Toilet”Phobia(fearofpublic
restroomsetc.)o Traumao Trichotillomania
(HairPulling)o Wartso WeightLosso WhiteCoat
Syndrome/Hypertensiono Writer’sBlocko Other___________________________o __________________________________o __________________________________o __________________________________
CLIENTBILLOFRIGHTS
ContactInformation: TocontactHemisphereHypnotherapy,youcanreachusbyphoneat508-340-9122,[email protected]
NOTICE: Hypnotismisaself-regulatingprofessionanditspractitionersarenotlicensedbystategovernments.CarlaChalahisneitheraphysician,noralicensedhealthcareproviderandmaynotprovideamedicaldiagnosisorrecommenddiscontinuanceofmedicallyprescribedtreatments.Ifaclientdesiresadiagnosisoranyotherformofmedicaltreatment,theclientmayseeksuchservicesatanytime.Theclienthastherighttorefusehypnosisservicesatanytime.Aclienthastherighttobefreeofphysical,sexualorverbalabuseatanytime.Aclienthastherighttoknowtheexpecteddurationoftheworktobedone,andmayassertanyrightwithoutretaliation.CarlaChalahandHemisphereHypnotherapydonotpresentservicesasanyformofhealthcareorpsychotherapy,anddespiteresearchtothecontrary,bylaw,we/Imaymakenohealthbenefitclaimsforourservices.
Fees: Aninitialconsultationisrequired,whereafter,ifdeemedasuitablecandidateforhypnosis,sessionsarebilledinincrementsof3,6or10sessions.A3-sessionpackageistheminimumcommitment.Packagepricesarequotedonceathoroughassessmentismadeduringtheinitialconsultation.
Paymentisdueinfullattheinitiationofchosensessionpackage.Sessionsaftertheinitialsessionpackagemaybeobtainedonasession-by-sessionbasisandarediscountedifpurchasedinincrementsof3,6or10.Sessionpackagesareacommitmentandaresubjecttonorefunds.
Thepreferredmethodofpaymentiscashorpersonalcheck;however,creditanddebitcardsareaccepted.
Cancellation/ HemisphereHypnotherapyrequiresthatclientsprovideaminimumoftwenty-four(24)hoursReschedulingPolicy: advancednoticeofcancellationorrescheduling.Cancellationsorreschedulingrequestsafterthat
timewillforfeitthefundspaidandbechargedthefullpre-chargedsessionrate.Repeatedcancellations,reschedulingorno-shows,mayresultinterminationofaclient’ssessions,subjecttonorefund.
Initial______________________________________
Guarantee: Sincehypnosisinvolvesahumanfactor,itwouldbeunethicalandunprofessionalforCarlaChalah/HemisphereHypnotherapytoguaranteeresultsfromundergoinghypnosis/hypnotherapy.Enteringhypnosisrequirestheclient’scompletecooperationandconsent.Everyindividualexperienceshypnosisinauniqueway,whichmakeseachcaseandsessionunique.Ourservice’sresults,aswithdoctors,lawyersetc.cannotbeguaranteedduetothehumanfactor.Whatisguaranteed,isthatCarlaChalah/HemisphereHypnotherapywillprovidereliable,knowledgeableservice.FormerclientsofCarlaChalah/HemisphereHypnotherapyhavereportedverypowerfulchanges(SeeHemisphereHypnotherapyYelpReviewsand/orwebsitetestimonials).
Confidentiality: CarlaChalah/HemisphereHypnotherapywillnotreleaseanyconfidentialinformationwithoutthewrittenconsentoftheclient,exceptasprovidedbythelaw.
Minors: Appointmentsforchildrenundertheageof18requirewrittenconsentfromtheparentorguardianwhomustaccompanythemtoeveryvisit.
RELEASE:
IherebyauthorizeCarlaChalahandHemisphereHypnotherapy,includinganyassociatesortrainees,tousehypnotismwithmeforthepurposesoutlinedintheintakeform.Iunderstandthatthesuccessofmyhypnosisworkdependsgreatlyonmyownseriousparticipationandcooperation,andresultscannotbeguaranteed.
Initialheretoindicateyouhavereadtheabovesection______________
Iamawareandunderstandthatinsomecasesitmaybecomenecessaryforthehypnotherapist/storespectfullytouchmyhand,wrist,shoulder,orforeheadtoassistmeinrelaxation.Hypnosismayinclude,andmaybeenhancedbytheuseofmusic,environmentalsounds,soundeffects,aromas,subliminalmessaging,appropriatetapping,touching,holding,positioningorrepositioningofthebody,oranyothermethodsthatthehypnotherapist/smaybelievetobehelpfulandappropriateunderthecircumstances.Igivethepractitionerspermissionandconsenttodoso,andusethis,andothermethodsinordertohelpmeestablishabeneficialstateofhypnosis.
Initialheretoindicateyouhavereadtheabovesection______________
Iunderstandvoicemail,emailandotherformsofelectroniccommunicationorpostalmailcannotbeconsideredsecure,butdespitethisknowledge,IauthorizeCarlaChalah/HemisphereHypnotherapy/associatesortheirstafftocontactmeregardingmyappointments,billing,hypnosisinformation,newsletters,offers,orfollow-upatthecontactinformationprovidedbymeonmy“confidentialclienthistoryform”.
Initialheretoindicateyouhavereadtheabovesection______________
Ø Thiscontractisafullexpressionoftheintentofthepartiesandisconsideredthefinalagreementbetweenthem;anyguarantees,expressorimplied,areherebydisclaimed.Ihavereadthisentireagreementandagreetotheterms.
I,(PrintFullName)_____________________________________________________indemnify,holdharmlessandreleaseMrs.CarlaChalah,HemisphereHypnotherapyandassociatesfromanyandallliability.Iunderstandtheaboveinformationandguaranteethisformwascompletedcorrectlytothebestofmyknowledge,andunderstandthatitismyresponsibilitytoinformthisofficeofanychangestotheinformationIhaveprovided.
Signature________________________________Date___________________________