Southlake Hypnosis Intake Form
I have been advised by Katie Sandlin of the scope of this hypnosis practice and I give my full consent to receiving hypnosis sessions with Katie Sandlin. I understand that results vary and that the above named practitioner may not guarantee results. Hypnosis is not a replacement for medical treatment, psychological or psychiatric services, or counseling. I also understand that the hypnotist does not treat, prescribe for, or diagnose any condition. I understand that the practitioner is a facilitator of hypnosis and is not practicing any other profession that requires a license under the laws of the State of Texas. I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my shoulder(s), hand, wrist, or forehead in order to assist me in relaxation. I give the practitioner permission and consent to do so in order to help me establish a beneficial state of hypnosis. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability. I have accurately provided background information as requested by the hypnotist. I understand that confidentially regarding my sessions will be honored between Katie Sandlin and myself. This same confidentially is respected when working with minors under the age of eighteen. Do you understand and agree to the terms listed above? If yes, check the box below.
I understand that I am responsible for paying the total session fee for cancellations or missed appointments without 24 hours notice, payable at the beginning of the next session, in addition to regular charges. I understand that if I have pre-paid for a package of sessions and do not give 24 hours notice for a cancelled or missed appointment, one session will be forfeited from the package. If you agree to these terms, check the box below.
Matters regarding your sessions will be kept confidential except in circumstances of child abuse, being an imminent danger to yourself or others, or in the case of a subpoena of records. You grant me specific permission to release information to a specific individual or agency in those circumstances. Aside from the aforementioned exceptions, any information shared is kept confidential. From time to time, I also consult with other colleagues, but in this circumstance, clients are not identified by name. Your signature below constitutes you giving permission for such consultations. Do you accept the confidentiality agreement listed above? If yes, check the box below. .
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
East Timor (Timor Timur)
Papua New Guinea
Saint Kitts and Nevis
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States of America
Emergency Contact Name
1 / 2
Emergency Contact Number
When and under what circumstances did this issue begin?
How has this affected your life?
Has it ever been different?
What specifically about your issue is leading you to seek help?
Are you on any medication and have you ever been diagnosed with a mental illness? If so, please list.
Please provide the name(s) and contact information of your doctor(s) and/or therapist(s).
Do you give Katie Sandlin permission to contact your doctor(s) and/or therapist(s)? If yes, check the box below.
What other things have you tried to deal with the presenting problem?
What life style or attitude changes have been partially successful?
What is your one month goal, regarding this issue?
What is your six month goal, regarding this issue?
What is your one year goal, regarding this issue?
What are your three biggest personal strengths?
What are your hobbies?
What do you do to handle stress?
Acceptance Of Terms
By selecting this box, I am digitally signing this document and confirming that all submitted information is true, to the best of my knowledge.
Please enter any two digits
This box is for spam protection -
please leave it blank
2 / 2
Subscribe to comments