Disclaimer Online Hypnosis or Coaching Session

Full Name(required)

Email(required)

Date of birth(required)

1. How did you hear about me?(required)

2. What is the main reason for wanting a Life Coach or Hypnosis session?(required)

3. Do you feel blocked, confused, or stuck in your life?(required) Yes

No

If Yes, please explain

5. Have you ever been hypnotized before?(required) Yes

No

6. Are you currently in the care of a mental health professional?(required) Yes

No

If Yes, please explain

7. Are you presently on prescription medication?(required) Yes

No

If Yes, please explain

8. Do you have epilepsy or seizures? (required) Yes

No

If Yes, please explain

9. Have you had any addictions to alcohol, marijuana or any other mind altering substances?(required) Yes

No

If Yes, please explain

10. Any other addictions? (required) Yes

No

If Yes, please explain

11. Are you currently having suicidal thoughts?(required) Yes

No

If Yes, please explain

12. Please list any other additional information that I should be aware of.

I have read and agree to the information listed above in this disclaimer.(required)

Enter full date please(required)