Tell Me MoreI can’t wait to work together. Please share a little more so that I am prepared to support you. Name * First Name Last Name Parent or Guardian Information if client is a minor: Full Name Phone * Client or Parent/Guardian for minors (###) ### #### Email * Date of Birth * (###) ### #### How did you hear about us? * Tell me more about you: * What are your challenges right now? Anything else you would like to share? * Client understands Hypno-Coaching and/or Hypnosis/Visualization are for the purpose of stress reduction and relaxation and/or therapeutic benefit. None of the modalities performed are a substitute for medical or psychological diagnosis or treatment. Cynthia Clark, is not a medical doctor and does not diagnose conditions, prescribe or perform medical treatment, or interfere with the treatment of a licensed medical professional. All known medical conditions have been disclosed honestly to the practitioner and will be updated as needed and is the client's responsibility. Note: All results of our work together are ultimately the client’s responsibility. The Hypnotherapist is a guide in assisting the client to clear blocks and issues, helping them move toward desired outcomes. I agree to CANCEL WITHIN 24 HOURS of my appointment, otherwise you will be charged for that hour. I understand that any child abuse or physical abuse is required to be reported by the State of California. *I understand that there are no refunds for single sessions and/or packaged sessions and/or group programs. *All 1:1 packages are to be used within 6 weeks from the first session. By checking below I understand and consent: * I understand and consent Thank you!
