New Client Form

Name *
Phone *
Emergency Contact Phone *
Emergency Contact Phone
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 Intuitive Coaching & Hypnotherapy Terms & Conditions: 1. I understand that results vary and that the above-named practitioner may not guarantee results. 2. I understand that Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist/Hypnotherapist does not treat, prescribe for, or diagnose any condition. 3. I understand that the practitioner is a facilitator of 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 or 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 hypnotist/hypnotherapist. 7. I understand that confidentially regarding my sessions will be honored between Stephanie Renee Payne and me. 8. I understand that, depending on the state of my mental health, further psychiatric treatment by 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 hypnoanalytic counseling and hypnotherapy. 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 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 charged for a booked session if I fail to cancel my session 48 hours before my appointment.