Client Information Form The following form is to be completed by clients seeking hypnosis sessions. Your confidentiality is respected. Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Gender* Male Female Age*Date of Birth* MM slash DD slash YYYY Occupation* Years At Present Occupation* Marital Status* Single Married Divorced Separated Widowed Other Spouse's Name* Spouse's Occupation Children's Names and Ages:How Many People Live In Your Household*Church Affiliation or Preference Have You Ever Been Divorced?* No Yes Year(s) Divorced* Educational BackgroundYears of School Completed* Trade School / Military Service / College DegreesFamily HistoryParent's Nationality Is your father living?* Yes No Is your mother living?* Yes No # of Brothers# of SistersYour Birth OrderPermission ConsentPhysician Physician Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician PhoneDate of Last ExamTherapist Therapist Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Therapist PhoneDate of Last AppointmentI give my permission for Connie Madry C.M.Ht., to discuss any pertinent information with my Physician or Therapist named above.* I Do I Do Not Medical HistoryMedical HistoryPlease Check If You Have Any Of The Following Conditions: Allergies Excessive Alcohol Use Anorexia Arthritis Asthma Bulimia Cancer Crohn’s Drug Use Emphysema Epilepsy Hearing Loss Heart Condition High Blood Pressure Hypoglycemia Irritable Bowel Leukemia Thyroid Disorder Loss of Vision Low Blood Pressure Lupus M. S. Narcolepsy Sleeping Problems Speech Disorder Diabetes Other Other Medical Condition* Surgeries and Dates of SurgeriesMedications and VitaminsDo you have any intense fears? If so please describe below:Have you ever been in counseling of psychotherapy?* No Yes When?* For?* Result?* Have you experienced hypnosis before?* No Yes When?* Result?* For?* Hobbies?* Favorite Time of Year* Least Favorite Time of Year* Describe a place that you would choose for peaceful relaxation*Are you comfortable with elevators?* Yes No Are you comfortable with escalators?* Yes No List your desired hypnosis goals in order of priority:*Referred by Health Provider Relative Friend Yellow Pages Ad Other Please Name Referral Source Consent and Disclaimer Form I have been advised by Connie Madry C.Ht. for the purpose and scope of hypnotherapy and the methods of hypnotherapy to be used in my case and I give my full consent to receiving hypnotherapy sessions by the above mentioned hypnotherapist. I understand that the results obtained through hypnosis vary with each individual and that no specific results can be guaranteed by the above mentioned hypnotherapists. I understand that hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling. I understand that the hypnotherapist does not treat, prescribe for or diagnosis any condition. Nothing said or done by the hypnotherapist should be construed to be such. I also understand that the hypnotherapist is a facilitator of hypnosis and hypnotherapy and is not practicing any other profession that requires a license under the laws of the State of Michigan. I understand that in some circumstances, such as hypnosis for glove anesthesia or pain management, it may be necessary for the hypnotherapist to respectfully touch my hand(s), wrist, arms, or shoulder(s). I hereby consent to such touching by the hypnotherapist. I acknowledge that I am free to terminate any or all sessions at any time, and that I have agreed to participate in each session through my own consent. I understand that confidentiality regarding my sessions will be honored between my hypnotherapist and myself. Confidentiality is also respected when working with minors or clients under the age of eighteen. By signing below and submitting this form I hereby affirm under oath that: (1) I am 18 years of age or older; (2) I am the person identified above (or, if the person identified above is a minor, I am the parent or guardian of that person); and (3) the information provided in this form is, to the best of my knowledge, true and correct.Client Signature* Date* MM slash DD slash YYYY Parent or Guardian Signature*If client is under the age of 18 or under the care of a guardian. Date* MM slash DD slash YYYY Newsletter Add me to the hypnotherapy newsletter list.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.