Client Intake Form

Services Offered

Amy Rosner provides the following services:

Hypnotherapy, self-hypnosis training, practitioner training, neurolinguistic programming, guided imagery and life and health coaching

Hypnotherapy is an educational process that facilitates access to internal resources that assist people in solving problems, increasing motivation or altering behavior patterns to create positive change. The education of hypnotherapy is classified under Human Services in the Health and Human Services Division of the Classification of Instructional Programs by the United States Department of Education.

Services provided online or, in select cases, in person at my Mesa office.

My Commitment to You

I will use my expertise to facilitate the changes that are mutually agreed upon to be in your best interest in the shortest possible time.

Client Information

The following information will be used to aid in serving you as a client. Please answer honestly and know that answering yes or no to any particular question does not mean that you cannot receive services from this practitioner. Your honest answers serve in your receipt of appropriate care and service. All information will be kept confidential. If a question does not apply, please answer "N/A".

First name

Last name

Is it okay to use this email to confirm appointments, send audio files and/or send detailed information about our sessions?

Yes

Phone

Is it okay to leave detailed voice and/or text messages for you at this number?

Yes

Address

Age

What is the main reason you would like hypnotherapy sessions?

Medical conditions or challenges:

Are you currently under a physician’s care for any of the above conditions? If so, name of physician:

When was your list visit with a physician?

Was anything about this visit notable? If so, explain briefly:

Are you currently taking any medications? If so, what are the names of the medications and how do they affect you?

Have you spoken to your physician about hypnotherapy as an adjunct to your treatment?

Yes

Have you ever had any mental health treatment by a counselor, psychologist or psychiatrist? If yes, give a brief history of your mental health treatment and the results of your treatment.

Are you receiving any mental health treatment now? If yes, name of mental health professional:

Have you spoken to your mental health professional about hypnotherapy as an adjunct to your treatment?

Yes

The Co-Creative Process

In order to be more successful in reaching my goals, I (the client) agree to:

Be an active participant in my hypnotherapy experience and see myself as a partner in the transformative nature of this process.
Recognize that my thoughts, feelings, images and actions have a direct effect on the quality of my life.
Acknowledge that my well being depends directly on how well I care for myself physically, emotionally, intellectually and spiritually.
Accept that blaming others or myself is totally futile.
Take responsibility for my experience of life, because I create my life experience to the best of my ability in the moment with what I know right now.
I agree to be on time for my sessions and allow at least 24 hours of advanced notice should I need to cancel or reschedule a session (if I cancel or reschedule within 24 hours of a session I agree to be charged in full for that session with a credit card on file or an applicable prepaid plan or pass).

Limits on Confidentiality of Information

Clients have a right to expect that information revealed in sessions not be disclosed without extraordinary justification. The conditions that justify the release of information and by law must be reported to the appropriate agencies are the following:

Knowledge of child abuse or neglect.
Knowledge of senior citizen abuse or neglect.
A client poses a serious risk of suicide and is an imminent danger to self.
A client poses a threat of imminent danger to another person.
A judge, by issuance of a court order, may obtain information.
Report to law enforcement authorities knowledge of a felony that has been or is being committed.
In other situations, signed authorization for release of information is required.

Agreement

Hypnotherapy, self-hypnosis, guided imagery, regression, life and health coaching and neurolinguistic programming, like the practice of medicine, are not absolute sciences. I personally know of no case on record where an individual has been harmed by the use of these methods. I do know of thousands of cases where people of all walks of life have benefited greatly from the use of these methods. As a general practice, it is necessary for everyone taking part in private sessions, classes, workshops and seminars with Amy Rosner to sign this Release of Liability Agreement.

I am of legal age and, in consideration of my acceptance as a participant in this private hypnotherapy or coaching session, seminar, workshop, class or other training, I for myself, my heirs, my executors, administrators and assignees, do hereby release and discharge Amy Rosner and any of her employees, her employer or other participants in any of the activities from all claims of damages arising from or growing out of my participation in said activities. I agree that any claim of damages or disputes arising from my participation in hypnotherapy sessions, hypnotherapy regression therapies, neurolinguistic programming techniques, guided imagery, life coaching, health coaching, or events, should it arise, shall be settled by binding arbitration before an extra-judicial arbitration and mediation service selected by the parties. I further understand that recordings may be made at any of these events and that Amy Rosner and her organization retain the copyright to all of these recordings.

I understand that all services provided by Amy Rosner are for educational and self-improvement purposes only. I further understand that Amy Rosner does not practice psychotherapy or medicine and her services are therefore not offered as a substitute for counseling, psychotherapy, psychiatric or medical treatment. Consultation and/or referral from a physician or mental health professional may be required before hypnotherapy services are provided.

It is your right to refuse any aspect of Amy Rosner’s services and to seek the service of another provider at any time. Amy Rosner’s standard fee is $300 per session. Sessions are typically from 30 to 60 minutes in length. Cancellation or rescheduling of a session without at least 24 hours notice will result in a $300 charge for that session or the deduction of one session credit on the client's account if applicable. Refunds are not provided for past services or any recordings.

Signature

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