Hybrid Hypnosis ™ Intake Registration Form

Register For Your Hybrid Hypnosis ™ Therapy Intake Session

Complete the form below to register for UniQuely Northern’s Hybrid Hypnosis ™ Therapy Program. You are required to submit this form before your intake session.

All questions are mandatory.

By submitting the form below, you certify that you have read, understood, and agree to the information provided in the Alternative Healthcare Disclosure.

Your information is kept strictly confidential.

You can either fill out the form below, or you can click the button below to download it, print it, fill it out and return it to us.

Download The Intake Form

First Name

Last Name

Email Address

Phone

Address:

Select Where You Will Do Your Session:
In Office (Cave Creek, Arizona)Zoom

Have you ever been hypnotized before?
YesNo

Please explain

What do you want to accomplish through the use of Hypnosis?

List any previous efforts to accomplish this?

How did you hear about my services?

If this is a referral, who referred you?

Possible Presenting Issues

Please check the issues below that are present in your life that you are ready to overcome*

Nicotine AddictionInsecurity and Lack of ConfidenceAsthmaLearning ProblemsAnxietyLow Self-EsteemAthletic AbilityMemory ProblemsAttitudesNervousness and Nervous HabitsBed WettingNightmares and Sleep WalkingCompulsive BehaviorPainConcentrationPerformance AnxietyCreativitySchool ProblemsPhysical CoordinationShyness"DepressionSleep DisordersDivorce AdjustmentSpeech DifficultiesEating DisordersAlcohol DependencyFear of Medical PeopleStressFears and PhobiasSuicidal ThoughtsAddictionThumb-SuckingGrief and LossUncontrollable AngerHeadachesSadnessIllnessWeight ChallengesOther

Enter the issue that you need help with

Please read each point below. Submitting this form confirms that you understand each of the UniQuely Northern Hypnotherapy statements. You will be expected to meet your contractual obligations as outlined herein. Following these guidelines will lead to greater therapeutic benefits. Your co-operation is required for best results.

1. The effects of Hypnotherapy vary from person to person. The effects of Hypnosis can vary for a number of reasons. Reasons include, but are not limited to, expectation, belief, nervousness, and levels of suggestibility.

2. For Hypnosis to be effective, two components must be present…Belief + Expectation. The more you actively participate in the experience, the more likely you will be to receive maximum benefits and results from your Hypnotherapy Sessions.

3. Some people may see dramatic results very quickly, while others may see gradual results over time.

4. Hypnosis will not be effective if you are under the influence of mind-altering drugs or alcohol.

5. Hypnotherapy Sessions are 55 minutes each. Please arrive 5 minutes early for your Hypnotherapy Session if your Session is in person, or sign in to your Zoom account 5 minutes before your Session begins.

6. Hypnotherapy Session payments are non-refundable. Payment in full is required when you book your Hypnotherapy Session. A 24-hour notification is required for all cancellations. A $85.00 fee will be charged if adequate notice is not given.

By submitting this form, you certify that the following is true:

I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, stress reduction processes, and techniques for the purpose of vocational and /or non-vocational self-improvement.

I understand that the Hypnotherapy I am receiving is not a substitute for medical or psychological care.

I have been advised to discuss this Hypnotherapy with any Doctor who is taking care of me for my condition at this time.

Additionally, I should and will continue treatment of any illnesses.

Alternative Healthcare Disclosure

By submitting this form you agree that have read and understand the information included in the Alternative Healthcare Disclosure below:

(YOU MUST CHECK THIS) I have read and understood the terms and conditions above and wish to participate in Hybrid Hypnotherapy™ Sessions with Uniquely Northern. I certify that I have read, understood, and agree to the information provided in the Alternative Healthcare Disclosure.