CONFIDENTIAL CLIENT INTAKE FORM Please Print Clearly
City: _________________________________________ State: ________________________ZIP: ___________
Phone #: Home (_________)_________________________ Cell # (________)______________________________________
Business Address: _________________________________________________________________________________________
Date of Birth: _________________________________________ Age: _____________ Sex: (M) (F) Marital Status: M D W
Contact Lens: During hypnosis your eyes will be closed for about 45 minutes. If your contacts will cause eye irritation, remember to bring lens holder and solution so you can remove them just before hypnosis.
Do you have a hearing problem? __________ Please tell me so I can position you for optimal hearing. If you normally wear a hearing aid, please use it as you will have your eyes closed and will not be able to lip-read during a session.
How did you hear about me? _________________________________________ If referred by someone, may I send him or her a thank you note? _______
Their name and address if known:
Your primary reason or goal for today’s session:
Other problems or goals, which may possibly be included with today’s session or in a future session:
NOTE: THE SERVICES I OFFER ARE NOT MEANT TO BE SUBSTITUTES FOR PSYCHOLOGICAL OR PROFESSIONAL COUNSELING. HYPNOSIS IS NOT TALK THERAPY. IF YOU HAVE AN ONGOING MENTAL HEALTH PROBLEM, PLEASE CONSULT A PROFESSIONAL LICENSED BY THE STATE OF Florida.
I may make general references to God, source, a higher power, or universal force or power. Is that OK or do you have other preferences?
Have you ever been hypnotized before? _______ When: __________
Group or Individual? (Y) (N)
Was it helpful? (Y) (N)How long? _____
What did you like or dislike about it? _________________________________________________________________________________________________
Please share anything else that would be helpful to know about you, (i.e., recent life-changing events such as deaths, divorce, relationships, job changes, health issues, past abuse, etc.) The better I know you, the more I can personalize your individual session.
CLIENT BILL OF RIGHTS CONSENT FORM
CONTACT INFORMATION: My name is RON DEWALD, I am a Board Certified Hypnotist (BCH) and Hypnosis
Instructor (HI) I can be contacted through my website, RonaldDeWald.com or by telephone (772) 286-0886.
EDUCATION & TRAINING: I completed Basic, Intermediate and Advanced training at Omni Hypnosis Training Center, 850 N Woodland Blvd, Deland Fl., to become a Certified Hypnotist. I have completed hundreds of hours of additional training. I am a Certified Member of the National Guild of Hypnotists, National Board of Hypnosis, all of which require annual continuing education to maintain my training at a high level. I am also a Certified Instructor for Hypnosis through the National Guild of Hypnotists.
NOTICE RONALD DEWALD does not treat, prescribe for, or diagnose any condition. He is a properly trained facilitator of hypnosis 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. RONALD DEWALD 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.
REDRESS: I am a certified member of the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards. If you ever have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the National Guild of Hypnotists at P. O. Box 308, Merrimack, NH 03054-0308, (603) 429-9438, to seek redress. Other services than my own may be available to you in the community.
FEES: The charges for my services are: General Hypnosis $450 per hour or as stated for certain sessions,
Group Sessions, as announced. Payment is due in full at the time of service. I accept cash, check, MasterCard, Visa, and Discover Card. Fees subject to change. The current fees will be honored for 6 months. Also see Cancellation Policy and Guarantee Policy. A $50 fee will be assessed for all returned checks.
CANCELLATION POLICY: My time is my income and my hours are by appointment. Your appointment time is reserved exclusively for you. Please arrive promptly to obtain your full session. I require a 24-hours cancellation notice. Even then, it is unlikely I can fill your time slot. Unless cancelled, you are financially responsible for the time reserved. If you must cancel or reschedule an appointment due to an emergency, please notify me as soon as possible. Thank you for your consideration.
CONFIDENTIALITY: Anything you tell me is held in strict confidence. I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you.
MINORS: Appointments or classes for children under age 18 require written permission from parent or guardian who must accompany the client at the first appointment.
INSURANCE: I do not file insurance or any other third party claims. Insurance companies usually consider hypnosis as an alternative therapy and therefore do not cover it. Upon request, I will provide a statement for Flexible Spending Plans or Employer Programs.
MY APPROACH: I believe that individuals have the right to choose, or practice, alternative or complementary self-improvement services. Hypnosis is safe and non-invasive. It is a wonderful tool that you can use to help yourself. The services I render are held out to the public as a form of motivational coaching and education, combined with instruction in self-hypnosis. I do not represent my services as any form of health care, psychotherapy or counseling and despite research to the contrary, by law I may make no health benefit claims for my services. Hypnosis is not meant to be a substitute for psychological or professional counseling. If you have an ongoing mental health problem, please consult a professional licensed by the State of Florida. I use hypnosis to motivate clients to eliminate negative or unwanted habits, facilitate the learning process, improve memory and concentration, develop self-confidence, eliminate stage fright, improve athletic ability, reduce stress and for other social, educational and cultural endeavors of a non-medical nature. In general, I help people to cope with the normal problems of everyday living by utilizing various techniques of hypnosis. Hypnosis reduces stress, which is a beneficial adjunct for many medical or mental health disorders. Hypnosis can be used to reduce pain, discomfort and improve certain health problems. For anything related to pain relief or other medical or mental issues, I will need a written referral from your applicable licensed medical, dental or mental health professional. All other issues may be self-referrals.
CLIENT CONSENT RELEASE: I hereby agree, voluntarily and freely, to undergo hypnosis. I further release RONALD DEWALD, Certified Hypnotist, its employees and agents, from any and all claims of injuries, harmful effects, and all other consequences, whether or not presently known, which may result from this procedure at this time and any future time that I elect to undergo hypnosis through this organization. I declare that I have read this consent and release, and that I fully understand and agree to its terms.
Client Signature (If under 18, must be signed by parent or legal guardian.)
Printed Client Name_______________________________________________________
Please keep a copy for your reference.