Welcome to the Anderson Hypnosis Center! Please fill out your client intake information below. Name * First Name Last Name Date of Birth * Email * Do you have a nickname you prefer? Please write it below. If not, just skip this step. Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Preferred method of contact: * Phone Email Best Time to Contact You: * Morning Afternoon Evening No Preference Emergency contact: In the event of an emergency, whom should we call? * Please list name and phone number How did you learn about Anderson Hypnosis Center? * Have you ever sought professional advice for an emotional issue? If so, please explain. * What do you hope to accomplish in this/these sessions? * Have you made any previous efforts to make these changes? If yes, please explain what you've tried. * Do you have any fears about hypnosis? * Yes, I'm nervous Not at all I'm not afraid, but I do have some questions. What is your dominant hand for writing and working? * Right Left Both - ambidextrous What are your areas of interest for treatment? Select any that apply. * ADD/ADHD Anxiety Bed Wetting Concentration Confidence Control Issues Cravings Depression Fears Focus Forgiveness Guilt Grief Insecurity Lack of Motivation Nail Biting Pain Management Panic Attacks Passive Aggressiveness Procrastination Self Esteem Self-Hypnosis Sexual Dysfunction Shame Sleep Disorders/Insomnia Sports Performance Stop Smoking Stress Trauma Weight Loss Worry Other, Not Listed What are your top 3 interests, either from the list above or that you can describe? * Please review our client agreement here before your appointment. We can discuss and sign it in person at your first appointment. CLIENT AGREEMENT I understand that Wally Post is a Certified Consulting Hypnotist and unconscious coach, and not a medical doctor or psychologist; that he cannot diagnose disease, prescribe, medicines, or treat medical conditions or disorders. I also understand that the coaching and training I am receiving from Wally Post is not a substitute for medical care. I have also been advised to discuss this process with any doctor who is currently treating me or now or will treat me in the future. Additionally, I should continue any treatment of any new, current or past illnesses. I am willing to be guided through various methods, including relaxation, visual imagery, creative visualization, hypnosis, neurolinguistic programming (NLP), Emotional Freedom Techniques (EFT), Graph Analysis and Stress Reduction processes for the purpose of vocational or avocational self-improvement. I also agree that Wally Post, or myself may terminate this relationship at any time and for any reason whatsoever. I realize that although Wally Post has considerable training and a decade of experience, the training and insight he provides are not a cure. I accept that I am paying for his time, expertise, and insights, irrespective of any particular result. I’m responsible for payment of my appointments unless they are cancelled the day before. Not responding to the confirmation text is not a form of cancellation. All clients under the age of 18 will need the consent of an adult who can be present at their appointment. * Agree Thank you! We will be in touch!
