Spirit Guides, LLC
Client Information
1. Name: __________________________________ Date: ___________
2. Address: _________________________________________________
3. City: __________________________ State: _______ Zip: _________
4.
Day Phone: ________________ Evening Phone: _________________
5.
Email Address: ____________________________________________
6.
Occupation:_______________________________________________
7.
Date of Birth: ___________________Age: ________
8.
If you are currently under the care of
a doctor or psychologist, do you have their
permission for a hypnosis session with a hypnotist?
Yes ___ No
____ Not Applicable ____
9. Do
you have any medical conditions or psychological history that the hypnotist
should
be aware of before the hypnosis session?
Yes ___ No ____
Not Applicable ____
If yes, please explain ____________________________________
_________________________________________________
10. Have you ever been hypnotized and/or regressed? Yes ___ No ___
If yes, when and describe your experience:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
11. What would you like to accomplish in this session? ___________________
___________________________________________________
___________________________________________________
___________________________________________________