True North Hypnosis & Wellness


Prior to your first session, please complete and submit your client questionnaire to us. 

Name *
Name
Phone
Phone
Address
Address
Personal Status (check one)
Are you experiencing any of the following: (please check all that apply)
I hereby authorize True North Hypnosis LLC to hypnotize me for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability to relax and desire to create change in myself. I understand that because the results of my sessions depend greatly upon my own serious participation that True North Hypnosis LLC cannot offer any guarantee of the success of my treatment. I am aware, however, that True North Hypnosis LLC will do everything reasonably in their power to ensure my success. Signed:
By entering your first and last name, you are electronically signing our release statement and submitting by email to our office *
By entering your first and last name, you are electronically signing our release statement and submitting by email to our office