Client Interview
Name: ______DOB: ______
Address: ______
Home phone: ______Cell: ______
Email: ______
Occupation: ______
Marital status: Married ___ Single ___ Divorced ___
Children: ___ Ages: ______
Referred by: ______
Doctor: ______Phone: ______
Please note that all questions asked help me to understand how you think, what your inner beliefs are and even your outlook on life. All of your answers will help me help you. Be as specific and detailed as possible.
Have you had hypnosis before? ______Setting? ______
Why have you chosen hypnosis? ______
What goals do you wish to achieve? ______
______
Symptoms or current difficulties? ______
How long? ______
How does stress affect you? ______
When are you most stressed? ______
2.
What is your religious background if you have one, and what are your current beliefs about death? Do you believe in God or a Higher Power?
______
Medical History:
Are you or have you ever been treated for schizophrenia, psychosis, depression, anxiety, fits or convulsions? If yes, when, and what was the treatment?
______
Do you have any physical/mental disabilities that are not apparent to the casual observer? (E.g. Dyslexia, etc)
______
Have you ever been physically, sexually or emotionally abused? (If yes, please explain) ______
3.
Do you have any siblings and what are their ages?
______
How has this condition or reason you are seeing me for, affected your life?
______
______
Are you taking any medications and what are they for?
______
What other modalities have you tried to help with this condition or situation?
______
How did they work or not work for you?
______
Do you have any ideas as to why they did or did not work?
______
How has this condition or situation served you in a positive or negative way?
______
4.
What might be expected of you if this condition or situation were gone tomorrow?
______
Describe how your life would look when this condition or situation is gone:
______
SESSIONS:
The number of sessions generally will vary from a minimum of three to several visits depending on the behavior modification desired. Sessions are designed to meet the individual needs of each person. Each Client is provided with a CD of his or her session to reinforce the desired behavior modification if hypnosis was used in that session. Some techniques may not require a CD such as Emotion Freedom Therapy (EFT) Time Line Therapy (TLT).
Gwenn Henkel begins working with you before you meet as she will be studying your information on this form and determining what methods of techniques she believes will work best for you. You are also free to contact her between sessions if you are having challenges or have questions.
Gwenn Henkel has informed the Client that she does not treat with medications or diagnose emotional, medical or psychological disorders, but is engaged in working for Client’s relaxation, self-improvement and behavioral changes.
Gwenn Henkel has informed the Clientthat the services to be performed are hypnotic induction and relaxation techniques and possibly some other mind-changing techniques such as Time Line Therapy and Emotion Freedom Therapy. Gwenn Henkelhas informed Client that she is a Certified Medical Hypnotherapist, Certified Hypnoanaesthesiologist, a Master Hypnotherapist, and a Reiki Master Practioner, and also a non-denominational minister.
5.
The Client acknowledges and understands that California has specific laws pertaining to the use of hypnosis to enhance or recover aid in testifying in criminal matters and that those laws may also impact civil cases if the hypnosis is used for the same purposes. Use of hypnosis to aid memory or recall for court testimony may result in the inadmissibility of that testimony.
The Client has been advised to contact his/her attorney if any question exists in his/her mind as to whether he/she may affect legal rights in matters currently pending by the use of hypnosis.
The Client has advised Gwenn Henkelthat he/she is not currently involved in any criminal or civil matters and is not seeking to enhance or develop memories for use in litigation. The Client agrees to hold hypnotherapist harmless, to defend and indemnify hypnotherapist from any claims including attorney’s fees and costs related to the so-called creation of memories or testimony that may arise or be related.
The foregoing is true and correct to the best of my knowledge and I agree to be bound by my own representation.
FEES:
The first session is 1 ½ hours and the fee is $300.00. All following sessions are $190.00 / hour. An additional $50.00 will be charged for any time up to 30 minutes over the scheduled appointment time if time permits. The Stop smoking Program consists of 2 sessions and the fee is $760.00. Each session is an hour and a half to two hours if needed. In the unlikely event, that a follow up smoking session is needed, the fee is $190.00, the hourly rate. Inner Child, Past Life Regressions, and Time Line Therapy may be 1½ -2 hours long at the hourly fee of $190.00 adding $50 for each additional 30 min.
Package of 4 Hypnosis or Reiki sessions pre- paid at first session allows you to have the 5th session for FREE, a savings of $190.00. People on fixed incomes are entitled to flexible fees to be discussed before first appointment. Payment plans also available.
6.
CONFIDENTIALITY:
All your records are confidential. Your records are released to your MD only upon your written authorization.
CANCELLATIONS, BEING LATE, AND NO SHOWS
Please notify the office at least 24 hours prior to your appointment if you must cancel or change appointment time. A fee for the amount of the session missed will be billed if you fail to call within 24 hours. (You will not be billed for missed session due to emergency situations)
15 minutes late it is considered a missed appointment. You will not be seen and you will be charged for the amount of your session. If you know you will be late and notify office ahead of time, you will not be charged.
If you do not show up for your appointment, you will be charged for the amount of the appointment session.
OFFICE HOURS:
Monday through Friday 10 AM – 6 PM
One Saturday a month 10 AM – 3 PM (chosen each month)
*Client promises not to listen to hypnosis CD’s while driving a vehicle or operating heavy machinery.
Client acknowledges that he/she has read and understands all of the terms and conditions above.
Signature: ______Date: ______
Please fill out and return before your scheduled appointment. Thank you.
Entrancing Life Hypnotherapy
961 Laurel Street * Ste 206
San Carlos, CA. 94070
650 380-2494 *