New Client Form

Name *
Phone *
Emergency Contact Phone *
Emergency Contact Phone
Have you worked with a life and/or career coach before?
Have you experienced hypnosis before? *
Are you more analytical or creative? Please choose the most dominate.
Marital Status *
Children? *
Do you have trouble sleeping? *
Do you wear contact lenses? *
You will have your eyes closed for part of our meeting. Will this cause you any discomfort? *
What type of learner are you? (If you are not sure, just go with your gut.) *
Please check all that apply. *
I mainly consider myself... Check all that apply.
Stephanie Renee Payne Life and Career Coach Terms and Conditions: 1. I understand that results vary and that the above-named practitioner may not guarantee results. 2. I understand that Life Coaching, Hypnosis, and/or Hypnotherapy are not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Life Coach, Hypnotist/Hypnotherapist does not treat, prescribe for, or diagnose any condition. 3. I understand that the practitioner is a facilitator of changing behaviors through actions and hypnosis or hypnotherapy and is not practicing any other profession that requires a license under the laws of the State of California. 4. I have been advised that I am free to terminate any and all sessions at any time. 5. I have agreed to participate in each session to the best of my ability. 6. I have accurately provided background information as requested by the practitioner. 7. I understand that confidentiality regarding my sessions will be honored between me and Stephanie Renee Payne. 8. I understand that, depending on the state of my mental health, further psychiatric treatment may be needed and will be suggested to me and documented by Ms. Payne if she determines my situation to be outside the scope of her practice. 9. I agree to pay Stephanie Renee Payne for all services rendered in a timely fashion if working with a payment plan; otherwise, I understand all monies are due before each session unless other arrangements have been made in writing. Sliding scale payments are available upon request. 10. I understand that all single sessions, and/or packages are non-refundable. However, we may consider extenuating circumstances on a case-by-case basis. 11. I understand that I will be charged for a booked session if I fail to cancel my session 48 hours before my appointment.

Clicking “SUBMIT” constitutes your agreement with the above terms and conditions in their entirety. Please feel free to contact us with any questions or concerns at 888-407-4577.