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Minor Medical Intake Form

DISCLAIMER: The Hypnotist is not a healer. The Hypnotist can only facilitate the session. Hypnosis is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or of other qualified health providers with any questions you may have regarding a medical condition. All the information you provide below, is private and protected. The following questions are only to better prepare me, the practitioner, for the hypnosis session. The more information I know, the better the experience.

Please select one option.
What is your relationship to the child?
Have you ever been hypnotized?
Are you currently taking any medicine?
Do you live with any of the following?

I will reach out shortly!

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