The Hypnosis Release form is here for you

Wayne Walker
Reflective Mind Hypnosis

STRICTLY CONFIDENTIAL

PERSONAL DETAILS

First Name *

Last Name *

Email *

Phone *

Date of birth *

Marital Status *

Address *

City *

State *

Postal code *

Organization

Occupation

HEALTH

Physician

Physician Phone

Medications

Have you had, or do you now suffer from any prolonged illness?

Under what circumstances does the issue affect you? *

How has this issue affected your life? *

What specifically about your issue is leading you to seek out hypnosis as a means of help? *

Have you tried other kinds of therapies? *

Yes

Please explain what other therapies you tried and if they were successful.

FROM THE LIST BELOW CHECK THE AREAS THAT CONCERN YOU

Anger

Addictions

Smoking

Drinking

Drugs

Gambling

Food

Achieving Goals

Anxiety

Career

Childhood Problems

Concentration

Confidence

Compulsive Behavior

Depression

Exams

Eating Problems

Fears

Guilt

Motivation

Memory

Nerves

Pain Control

Panic Attacks

Phobias

Public Speaking

Fertility

Relationships

Relaxation

Stress

Self Esteem

Sleep Problems

Sexual Problems

Skin Problems

Weight Problems

Anorexia

Bulimia

Fibromyalgia

Chronic Fatigue Syndrome

Impostor Syndrome

Have you ever been treated for emotional problems? *

Yes

If yes, please explain.

Have you ever been hypnotized before? *

Yes

If yes, please explain.

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

Any previous efforts to solve this problem?

Yes

Do you have any fears or phobias? *

Yes

If yes, please explain

Think back when you where younger and describe your relationship with you Father and Mother? *

How many siblings do you have and how is your relationship with them? *

Are you currently married? If so how long and how is your relationship with your spouse? *

Do you smoke? *

Yes

Are you overweight? *

Yes

What is your diet like? *

Healthy

Bad, Junk food, Fast food

A little of both

What is you spiritual belief system? *

Christian

Jewish

Atheist

Agnostic

New age

I believe in angels

Other

Hear About Us *

Medical Referral

Relative

Friend

Newspaper

Radio

Facebook

Google

Podcast

Name of the Podcast

I understand these methods to be a conditioning process, whereby an individual is taught to use their own abilities for their benefit and well-being. With this understanding, I hereby grant the Hypnotist(s) of Reflective Mind Hypnosis permission to hypnotize me or the minor child whose name appears at the top of this form. I (we) further grant permission for the sessions to be recorded/taped as needed. *

I agree

I also understand if I decide to move forward with this process that no refunds will be given after sessions are complete, on any used sessions and all sessions must be completed within six months unless otherwise discussed and agreed to by Mr. Walker. I also understand I am responsible for scheduling my sessions through the online portal. I am aware however, that Mr. Walker will do everything reasonably in his power to ensure my success. I certify that I am at least 18 years of age. *

I agree

Consent

Text

Wayne Walker of Wayland Harold Walker Jr. offers which includes hypnosis and can include regression techniques.

Hypnosis is entirely natural, safe, and relaxing. With Hypnosis clients remain conscious and in complete control throughout but will feel a strong sense of relaxation.

Hypnosis alone does not offer any guarantee of success. The client must want change and be open and motivated. The client must be willing to fully participate in the session and to implement the recommendations of the hypnotherapist and to listen to the recording(s) given to reinforce the session(s).

I understand that Wayne is not a licensed physician, psychologist, or medical practitioner and the information, techniques, methods, recommendations by Wayne are not intended to substitute for diagnosis and care by a qualified physician, nor to encourage the treatment of any illness by persons not recognizably qualified. If you use hypnosis and are under medical care for ANY condition, DO NOT make any adjustments to any prescribed medication without the approval of your doctor. If in any doubt, you should contact your physician.

I give Wayne full permission to make audio recordings of her voice during the session(s). I understand that if a recording (or recordings) are made during or after my session(s), Wayne holds full copyright over any forms of media that may be produced and distributed to me.

I hereby grant permission to Wayne to respectfully lift my arm, touch my shoulder, or rock my head during the course of my hypnotherapy session(s) in order to facilitate the deepening process.

I consent that Wayne release information to a specified individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; or if I, as a client, am in imminent danger to myself or others.

I hereby give Wayne full permission to hypnotize me and to use Hypnotherapy in the knowledge that I do so at my own risk. I accept that while hypnosis has a high success rate, Wayne does not guarantee any results and the success of the session(s) depends greatly on my own ability and desire to affect change.

I release Wayne from any liability or claims concerning my mental and/or physical well-being during or following the treatment that has been outlined and agreed upon by filling out this form.

I understand that if I am epileptic or suffer from a psychotic illness it is not generally recommended that I undergo hypnotherapy. I hereby agree that by signing this form that I do not currently suffer from these disorders.

I understand that Wayland Harold Walker Jr. does not offer refunds for unused/missed sessions in packages and that all sessions are to be used within 6 months.

I can confirm that I have read the above and understand the process of hypnotherapy and accept these terms and conditions.

Consent Signature *

Clear

*** Please phone/text/email at least twenty-four hours in advance in the unlikely event that you need to reschedule your appointment. Failure to do so wastes time, and you will be charged the full fee for the missed appointment.

Change starts with Desire

Kindly Fill This Release Form,