CONFIDENTIAL CLIENT INTAKE FORM AND RELEASE Please answer all questions and sign. Fax to 888-958-1894 or e-mail to: seminars@easywillpower.com or bring to appointment. Thank you. Last Name: ________________________First: _______________Appointment Date: __________________ Address: _____________________________________________________Apt. #_____________ City: _______________________________________ State: ____ZIP: __________ Email: _______________________________ Phone Nos.: Home (_____) _________________ Cell (_____) __________________ Work (_____)____________________________ Employer: _____________________________________ Occupation: ____________________ Do you enjoy your work?___________________________________________________________ Date of Birth: _______________ Age: _____; ?M, ? F; Marital Status: ?S, ? M, ? SO, ? D, ?W; Spouses name____________________________________________ Names and ages of children_________________________________________________________________________ Do you have any current health problems?_____________________________________________________ Do you have a favorite place? Please describe it:________________________________________________ If you could imagine the most peaceful, safe place, what would it be?________________________________ _______________________________________________________________________________________ How is your sleep?________________________________________________________________________ Are you taking any medication (if so, list)?______________________________________________________ What are your favorite pastimes/hobbies?______________________________________________________ What things do you like to do?_______________________________________________________________ What behaviors get in the way of your happiness?_______________________________________________ What would you like to start doing (or do more of)? ___________________________________________________________ What would you like to stop doing (or do less of)? ___________________________________________________________ What do you do for fun and relaxation? _______________________________________________________ What makes you laugh? ___________________________________________________________________ Do you observe any religious or meditative practices?____________________________________________ WEIGHT LOSS ONLY How much weight would you like to lose?_______________________________________________________ What specific behaviors are causing you to gain/hold onto weight (e.g. overeating, binge eating, snacking, emotional eating, night eating, not exercising)? __________________________________________________ When were you happiest with your weight? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What was happening at that time? ____________________________________________________________ What methods have you tried to lose weight? ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________ What have you learned from your experiences? What works for you and what doesn't work for you, with weight loss? ________________________________________________________________________________________ What are your reasons for wanting to lose weight at this time (remember that motivation is the key to success)? ______________________________________________________________________________ What outfit do you want to wear when you achieve your ideal weight? _______________________________ Wearing contact lens? _____ During hypnosis your eyes will be closed for a period of time. If your contacts will cause eye irritation, you may want to bring your lens holder and solution so you can remove them just before hypnosis. Hearing problems? _____ ?PRIMARY GOALS OF SESSION (you can have more than one): _______________________________________________________________________________________________________________________________________________________________________________; ?Stress Management; ?Sleep Improvement; ?Motivation/Procrastination; ?Confidence; ?Relationships; ?Weight Management; ?Attitude/Outlook; ?Fear/Apprehension: ?Self-Esteem/Self-Image; ?Facilitate Wellness; ?Change Habit(s)_______: ?Medical/Mental Health ?Quitting Smoking, ?Stop Drinking Are you under the care of a mental health professional? ____________________ Any previous experience with hypnosis?____ When: ________ Reason: ___________________________ Group or Individual?_____ How did you find us? ? Website; ? Google; ? Face Book; ? Referral____________________; ? Other ______________________ Please read and sign the OFFICE POLICY & CONSENT FORM OFFICE POLICY & CONSENT FORM Rena Greenberg Hypnosis Session CONTACT INFORMATION: My name is Rena Greenberg (Certified Hypnotist). I can be contacted through my office, Wellness Seminars, Inc, 414 26th St West, Bradenton, Florida 34242, (800) 848-2822, email renagreenberg@easywillpower.com or through my website, www.easywillpower.com. Office hours are by appointment only. CANCELLATION POLICY: My time is my income and my hours are by appointment. Your time slot is reserved exclusively for you. Please arrive promptly to obtain your full session. A 24-hour cancellation notice is required, except in an emergency or inclement weather. If you must cancel or reschedule due to an emergency, please notify me as soon as possible. Thank you for your consideration. PREPAID SESSIONS: Payment is due in full prior to confirming appointment. The above Cancellation Policy also applies to any programs with prepaid sessions. Except for emergencies or bad weather, 24-hours notice is required. Failure to keep your appointment or non-emergent short-notice cancellations may result in the forfeiture of a prepaid session. No refunds will be given for unused prepaid sessions. All prepaid sessions will expire after twelve months. CONFIDENTIALITY: I will not release any information to anyone without a written authorization from you, except as provided for by law. MY APPROACH: I understand that Hypnotherapy is not a replacement for traditional medical or mental treatment and should not be used as such. I understand that Hypnosis is not a replacement for my primary care physician's care nor is it to be used for, or is it a replacement for any medications, diagnosis or treatment of a licensed medical doctor. Hypnosis is a form of motivational coaching and education, combined with instruction in self-hypnosis. I do not represent any of my services as any form of health care, psychotherapy or counseling. I use hypnosis to motivate clients to eliminate negative or unwanted habits. Relaxation techniques, Biofeedback and guided imagery may be utilized. I believe that thoughts and attitudes can influence how we feel and that hypnosis can help you change habits, focus on the positive, and visualize a state of wellness. GUARANTEE AND REFUND POLICY: No guarantees as to the effectiveness of hypnosis for your particular problem are made or implied, as it is impossible to guarantee human behavior or compliance. Therefore, no refunds for services are given. Hypnosis is not a quick fix or magic pill. A hypnotist is considered a guide or facilitator. You assume equal responsibility by making a commitment and allowing yourself to be guided into a state of hypnosis. No one can make you do something against your true will. I sincerely want you to succeed and pledge my efforts to help you to the best of my ability. CLIENT CONSENT & RELEASE: I hereby agree, voluntarily and freely, to undergo hypnosis. I further release Rena Greenberg and Wellness Seminars, Inc., as well as her personal and business properties, from any and all claims of injuries, harmful effects, and all other consequences, whether or not presently known to me, 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. I HAVE READ THIS CLIENT BILL OF RIGHTS AND I FULLY UNDERSTAND WHAT I HAVE READ. Client Signature:_____________________________________ Printed Name: ________________________________________ Date: ____________________ Page 4 of 4 1