CONFIDENTIAL CLIENT INTAKE FORM             Please Print Clearly                         

Name: __________________________________________________________ Date: ____________________________________

Address: ____________________________________________________________Apt. #________________________________
City: ___________________________ State: _________ZIP: ___________ Email: _____________________________________
Phone #: Home (____)________________ Cell # (____)___________________ Work (____)_____________________________
Employer: ________________________________________Occupation: _____________________________________________
Business Address: _________________________________________________________________________________________
Date of Birth: _____________________ Age: ______             Sex:  M      F               Marital Status:  S    M    D    W
Contact Lens: During hypnosis your eyes will be closed for about 45 minutes.  If your contacts will cause eye irritation, remember to bring lens holder and solution so you can remove them just before hypnosis.
Do you have a hearing problem? ____ Please tell me so I can position you for optimal hearing. If you normally wear a hearing aid, please use it as you will have your eyes closed and will not be able to lip-read during a session.
How did you hear about me? _________________________________________ If referred by someone, may I send him or her a thank you note? _______
Their name and address if known: _______________________________________________________________________________
Your primary reason or goal for today’s session: _________________________________________________________________
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Other problems or goals, which may possibly be included with today’s session or in a future session: _____________________

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How will your life be different when you reach your goal? _________________________________________________________

Do you have difficulty with any of the following? ___Ability to get to sleep; ___Quality of sleep; ___Self-esteem; ___Self-confidence; ___Attitude or outlook on life; ____ Energy level; ____ Stress level; ___Other _________________________________.

If stress plays a role in your problem: Is the source of stress known? _________________________________________________
Do you think caffeine or other stimulants contribute to your situation? __________________________________________________
Do you think alcohol or other drugs contribute to your situation? ______________________________________________________
Please complete the following as applicable:
Are you under the care of a physician now? ____ Dr. Name __________________________________________________________
Significant current health problems: ­­­­­­­­­­­­­­­_____________________________________________________________________________
List any significant past health or mental health problems and year—if you feel important for me to know: _____________________
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Are you currently under the care of a mental health professional? _______Name:_________________________________________
Have you been diagnosed with any of the following?  Seizure disorder ___; Obsessive-compulsive disorder ___; Depression ____;
Schizophrenia ___; Bipolar or manic-depressive ___; Post-traumatic-stress syndrome ___; Diabetes ____. Details of any yes answers: __________________________________________________________________________________________________________
Do you have any fears or phobias that interfere in your life? ______________________________________________________
NOTE: THE SERVICES I OFFER ARE NOT MEANT TO BE SUBSTITUTES FOR PSYCHOLOGICAL OR PROFESSIONAL COUNSELING. HYPNOSIS IS NOT TALK THERAPY. IF YOU HAVE AN ONGOING MENTAL HEALTH PROBLEM, PLEASE CONSULT A PROFESSIONAL LICENSED BY THE STATE OF Florida.

I may make general references to a higher power, creative force, or universal force. Is that OK or do you have other preferences? ___________________________________________________________________________________________________________

Have you ever been hypnotized before? ____ When: ______ Why:____________________ Group or Individual? (circle)

Was it helpful? ______How long? _____What did you like or dislike about it? ________________________________________

Please share anything else that would be helpful to know about you, (i.e., recent life-changing events such as deaths, divorce, relationships, job changes, health issues, past abuse, etc.) The better I know you, the more I can personalize your individual session.  ___________________________________________________________________________________________________________

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PLEASE READ AND SIGN THE NEXT PAGE, WHICH IS THE CLIENT BILL OF RIGHTS & CONSENT FORM THAT ALSO INCLUDES MY OFFICE POLICY.

NOTICE:  RON DEWALD does not treat, prescribe for, or diagnose any condition. He is a properly trained facilitator of hypnosis and is not practicing any other profession that requires a license under the laws and regulations of the State of Florida. Hypnosis is not a substitute for medical or psychological treatment. Hypnosis for subclinical purposes requires no referral. RON only practices therapeutic hypnotherapy within the guidelines of the law and Florida Statute 485, which requires a referral and oversight from a licensed practitioner of the healing arts.

REDRESS:   I am a certified member of the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards.  If you ever have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the National Guild of Hypnotists at P. O. Box 308, Merrimack, NH  03054-0308, (603) 429-9438, to seek redress.  Other services than my own may be available to you in the community.  You may locate such providers in the telephone book. 
FEES: The charges for my services are: $150 for initial visit/$75 follow-up for General Hypnosis; Group Sessions, as announced. Payment is due in full at the time of service. I accept cash, check, MasterCard, Visa, and Discover Card. Fees subject to change. The current fees will be honored for 6 months. Also see Cancellation Policy and Guarantee Policy. A $50 fee will be assessed for all returned checks.
CANCELLATION POLICY: My time is my income and my hours are by appointment. Your appointment time is reserved exclusively for you. Please arrive promptly to obtain your full session. I require a 24-hours cancellation notice. Even then, it is unlikely I can fill your time slot. Unless cancelled, you are financially responsible for the time reserved. If you must cancel or reschedule an appointment due to an emergency, please notify me as soon as possible.  Thank you for your consideration.
PREPAID VISITS: The same policy applies to prepaid visits. Except in an emergency, 24-hours notice is required. Failure to keep your appointment or short-notice cancellation will result in the forfeiture of a prepaid visit. No refunds will be given for unused prepaid sessions. All prepaid visits will expire after twelve months.                        
CONFIDENTIALITY:  Anything you tell me is held in strict confidence. I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you.
MINORS:  Appointments or classes for children under age 18 require written permission from parent or guardian who must accompany the client at the first appointment.
INSURANCE: I do not file insurance or any other third party claims. Insurance companies usually consider hypnosis as an alternative therapy and therefore do not cover it. Upon request, I will provide a statement for Flexible Spending Plans or Employer Programs.
MY APPROACH: I believe that individuals have the right to choose, or practice, alternative or complementary self-improvement services. Hypnosis is safe and non-invasive. It is a wonderful tool that you can use to help yourself. The services I render are held out to the public as a form of motivational coaching and education, combined with instruction in self-hypnosis. I do not represent my services as any form of health care, psychotherapy or counseling and despite research to the contrary, by law I may make no health benefit claims for my services. Hypnosis is not meant to be a substitute for psychological or professional counseling. If you have an ongoing mental health problem, please consult a professional licensed by the State of Florida. I use hypnosis to motivate clients to eliminate negative or unwanted habits, facilitate the learning process, improve memory and concentration, develop self-confidence, eliminate stage fright, improve athletic ability, reduce stress and for other social, educational and cultural endeavors of a non-medical nature. In general, I help people to cope with the normal problems of everyday living by utilizing various techniques of hypnosis. Hypnosis reduces stress, which is a beneficial adjunct for many medical or mental health disorders. Hypnosis can be used to reduce pain, discomfort and improve certain health problems. For anything related to pain relief or other medical or mental issues, I will need a written referral from your applicable licensed medical, dental or mental health professional.  All other issues may be self-referrals.
GUARANTEES: 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. Hypnosis is a tool you use to help yourself; therefore no refunds for services are given. I do pledge my efforts to help you to the best of my ability and I sincerely want you to succeed!
CLIENT CONSENT & RELEASE: I hereby agree, voluntarily and freely, to undergo hypnosis. I further release RON DEWALD, Certified Hypnotist, and l Hypnosis Anytime, its employees and agents, 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 acknowledge receipt of a copy of this statement.

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Client Signature (If under 18, must be signed by parent or legal guardian.)       Printed Client Name            Date Signed
Please keep a copy for your reference.
 Hypnosis Anytime (Revised 01/01/10)