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Jayson
Kenneth
AB/DL Hypnotherapy
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demographic information
First & Last Name
Email
Telephone Number
State
Date of Birth
Gender
Orientation
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact Email
May we contact your Emergency Contact according to policy?
Your emergency contact will only be contacted in the event of an emergency. Even then, the nature of our sessions will not be discussed. This will simply be used in the event that you are having an emergency and need help. You must agree to this in order to continue with our practice.
How would you prefer to be contacted?
Email
Call
Text
Are you currently under the care of a medical/mental health professional?
Yes
No
Please list all medical or mental health diagnoses:
Please list all medications, including supplements you are on
Have you ever been diagnosed with any form of epilepsy?
Yes
No
Have you ever experienced any form of psychosis?
Yes
No
Do you wear any of the following?
Glasses
Contact Lenses
Hearing Aides
Dentures
None of the Above
What is your dominant hand?
Right
Left
Ambidextrous
In your own words, please describe what you would like to work on with us:
If you have any fears, concerns, or anxieties relating to hypnosis, please describe them here.
Check all forms of hypnosis you've experienced in the past:
None
Stage Hypnosis
Hypnotherapy
Erotic Hypnosis
Audio Files - Erotic
Audio Files - Therapeutic
Aside from what you're being seen for now, are there other things that you'd like to work on in hypnotherapy?
Acceptance of Terms and Conditions
I have read the
Terms and Conditions
and agree to those terms.
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