CLIENT INTAKE FORM

I hereby give my full consent to receiving hypnotherapy OM SPACE Certified Clinical Hypnotherapist.

- I understand that the results obtained through hypnosis vary with each individual and that no specific results can be guaranteed.
- I understand that hypnotherapy is not a replacement for medical or psychological treatment or counselling.
- I understand that the hypnotherapist does not treat, prescribe for or diagnose any physical or mental condition.
- I understand that in some circumstances it may be necessary for the hypnotherapist to respectfully touch me on the hand, wrist, arms, shoulder or forehead as a means of helping me establish a beneficial state of relaxation.
- I hereby consent to such touching by the hypnotherapist.
- I have agreed to participate in each session to the best of my ability.
- I have accurately provided background information as requested by the hypnotherapist.
- I understand that the consent of all hypnotherapy sessions is private and confidential.
- Confidentially is also respected when the client is under the age of eighteen.