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| Unique ID | Name | Address | Phone | Gender Identity | Preferred Pronouns | Emergency Contact Name | Emergency Contact Relationship | Contact Phone | Contact Email | Are you currently being treated by a mental health or medical provider? | Provide information about your diagnosis/diagnoses: | Are you currently taking any medications (prescription, vitamin, supplement)? | Medications/Supplements | Have you ever been diagnosed with Epilepsy? | Have you ever been diagnosed with schizophrenia, DID, or any form of psychosis/dissassociation? | Choose Your Dominant Hand | In your own words, describe why you're being seen by A Little Hypnosis: | Have you ever been hypnotized before? | Describe your experiences: | What types of hypnosis have you tried? | Create Your Goals | Do you have any fears about hypnosis or achieving your goals? | Please, elaborate about those fears/concerns: | Consent | Terms of Conditions Consent | Signature | Entry Date | User | |||||||||||||
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| 13634 | Thomas Gallagher | United States | 201 | Right |
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I agree to the "Informed Consent" document presented below: | I agree to the terms and conditions listed below: | https://alittlehypnosis.com?page=gf_signature&signature=675e2efc03b916.23654267 | 14/12/2024 08:21 PM | ||||||||||||||||||||||||||||||||
| Unique ID | Name | Address | Phone | Gender Identity | Preferred Pronouns | Emergency Contact Name | Emergency Contact Relationship | Contact Phone | Contact Email | Are you currently being treated by a mental health or medical provider? | Provide information about your diagnosis/diagnoses: | Are you currently taking any medications (prescription, vitamin, supplement)? | Medications/Supplements | Have you ever been diagnosed with Epilepsy? | Have you ever been diagnosed with schizophrenia, DID, or any form of psychosis/dissassociation? | Choose Your Dominant Hand | In your own words, describe why you're being seen by A Little Hypnosis: | Have you ever been hypnotized before? | Describe your experiences: | What types of hypnosis have you tried? | Create Your Goals | Do you have any fears about hypnosis or achieving your goals? | Please, elaborate about those fears/concerns: | Consent | Terms of Conditions Consent | Signature | Entry Date | User |
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