Hypnotherapy Consultation and Consent Form

Client Details

Emergency Contact

Medical History



I hereby authorise the hypnotherapist named below to use hypnosis techniques on me for the purposes outlined in this form, and for future purposes that I may request.

I understand that hypnosis and regression therapy are not medical procedures and that no medical benefits are being offered to me.

I understand that the success of hypnosis and regression therapy depends on my ability to relax, and my desire to create change in myself.

I understand that, because the results of the sessions depend on my own serious participation, the hypnotherapist cannot offer any guarantee of the success of my treatment. I am aware however, that they will do everything reasonable in their ability to ensure my success.

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