Clinical Interview Intake Form

Name(required)

Email(required)

Phone(required)

Address(required)

Date of Birth(required)

What do you want to accomplish with hypnosis today?(required) Stress Management

Quit Smoking

Weight Loss

Overcome Fears

Test Taking

Medical Condition

Pain Management

Other

What is your prior experience with hypnosis?(required) None

Have been hypnotized at a stage show

Have been hypnotized one on one

Have listened to hypnosis recordings

Have read books on hypnosis

Have friends or family who have been hypnotized

What are your beliefs about hypnosis?(required) I think it can help me

I will try it and see what happens

I am a skeptic

Please list all medical and mental health conditions for which you are currently being treated:(required)

What do you want to accomplish with hypnosis?(required)

Please describe any fears or phobias:(required)

Waiver of Liability: The client voluntarily agrees to be a participant in hypnosis and / or coaching session under the direction of Melissa Conkling, CPH, and accepts full responsibility for any and all injury arising from the hypnotherapy and / or coaching sessions. (required)

Disclaimer: I, Melissa Conkling, am not a trained medical doctor or psychologist. At no time will I attempt to provide medical or mental health therapy. I advise that you seek a qualified doctor or psychologist if you need help with mental health issues. (required)

Guarantee and Refund Policy: No warranty and / or guarantee is given, expressed or implied, for satisfactory results from the hypnotherapy session, as it is impossible to guarantee human behaviors or compliance. Therefore, no refunds for services are given. The client understands that change is his/her responsibility. The hypnotherapist / coach is considered a guide or facilitator in the process.(required)

Methods Used: Specific techniques may include Body Relaxation/Progressive Muscle Relaxation, Guided Meditation, Regression, Behavior Modification, Guided/Visual Imagery, Emotion Replacement Therapy. The Client understands that the above modalities are not substitutes for regular medical care, and has been advised to consult with his/her medical doctor of health care practitioner for treatment of any old, new or existing medical conditions. (required)

Education and Training: Melissa Conkling is certified by the International Certification Board of Clinical Hynotists and was trained by Leah Agami. (required)

Fees and Payment Policy: Payment is due in full at the time of booking by cash, check, or credit card. Session fees are subject to review and change. Twenty four (24) hour cancellation notice required, otherwise client will be billed for the session. Credit for rescheduling of a missed or unused scheduled pre-paid package session will be honored for up to 30 days from the last scheduled session appointment. (required)

Minors: Appointments for children under 18 years of age require written consent from a parent or guardian, who must accompany them at each visit.(required)

Connecticut Hypnosis/Melissa Conkling reserves the right to refuse service to anyone, at anytime, for any reason. (required)

By submitting this form, I (the client) certifies that I have read the above statements and fully understand and accept the information described above, and agree to participate in a hypnosis and / or coaching session. (required)

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