- LifeStyle by Choice -
(ALL INFORMATION IS CONFIDENTIAL)
NAME ______________________________________________________ DATE ________________________ STREET ADDRESS ___________________________________________ STATE ______ ZIP __________________ HOME PHONE _____ ______________________ CELL PHONE ______ ______________________________ (I give you permission to be contacted via e-mail: YES _____ NO _____, home phone: YES _____ NO _____
cell phone: YES _____ NO _____ ) BIRTHDATE ________________ MALE _____ FEMALE _____ EMERGENCY CONTACT _____________________________________ PHONE _____ ____________________ Have you been hypnotized before? ________ When ___________ Results __________________________________ What is the reason(s) for you wanting hypnosis? Have you used other types of treatment for the above issue? YES ______ NO _____ If you have please indicate the type of treatment and its effectiveness: Are you experiencing any mental health issues at this time? YES _____ NO _____
Are you taking medication for the above? YES _____ NO _____
Have you ever been treated for any of the following? CHECK BOX BELOW.
Arthritis _____ Diabetes _____ High Blood Pressure _____ Heart trouble_____ Seizures/Epilepsy _____ Obesity _____ Anxiety _____ Stress _____ Depression _____ Broken Bones _____ Other _______________________________________________________________ Do you feel that you can gain control of the issue that you are here for today? YES _____ NO _____ AGREEMENT I am willing to be guided through mental and physical relaxation techniques, visual imagery, hypnosis, and or Neuro-linguistic Programming (NLP). I understand that there are no guarantees for changing human behavior throught this process. I also understand that the services I purchase from LifeStyle by Choice, LLC are not to be used as a substitute or replacement for professional medical or mental health advice or care.
SIGNATURE ____________________________________________ DATE ____________
LifeStyle by Choice, LLC
I got _____ or get _____ along with my mother all the time _____, sometimes _____, never _____ . I was called names during the age’s of __________________________, or I was never called names________________. Either my father _____or mother _____used alcohol or other drugs in excess.
Explain the drugs they used
Please add any other conditions, feelings or emotions which you experience: