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Hypnosis Intake Form

Birthday
Month
Day
Year
Are you currently under the care of a physician, psychologist, or psychiatrist?
Yes
No
Are you currently taking any medications for depression, anxiety, or neurological conditions?
Yes
No
Do you have a history of epilepsy or seizures?
Yes
No

Informed Consent & Waiver of Liability

Nature of the Service: I, the undersigned, understand that Hypnosis Coaching is a process of self-improvement and educational assistance. It is designed to help me use my own natural resources to create positive change. I understand that Grant Graham is a Certified Hypnosis Coach through the Mike Mandel Hypnosis Academy and is not a licensed physician, psychologist, or mental health counselor.

Not a Substitute for Medical Care: I understand that hypnosis is not a substitute for medical or psychological diagnosis and treatment. Hypnosis practitioners do not diagnose, treat, or prescribe for any physical or mental condition. If I am under the care of a medical professional for any condition, I am encouraged to stay in communication with them regarding my hypnosis sessions.

Confidentiality: All information shared in these sessions is strictly confidential and will not be shared with any third party without my written consent, except as required by law (e.g., threat of harm to self or others).

Guarantee & Results: I understand that while hypnosis is a highly effective tool for many, results vary from person to person. No specific results are guaranteed. My active participation and desire for change are essential to the success of the process.

Acknowledgment: By signing below, I acknowledge that I have read this document, understand its contents, and voluntarily agree to participate in hypnosis coaching. I release Grant Graham and Power Yoga Canada Sudbury from any and all liability or claims arising from my sessions.

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