Client Assessment Form Step 1 of 8 12% Please enter your contact information belowName* First Last Main Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation*HobbiesSpirituality/ReligionAge*Prefer Not to AnswerUnder 1818-2425-3435-4445-5455-6465 or AbovePLEASE answer, unless participation in the Witness Protection Program forbids you from revealing your age.Verify Permission*Yes, I am under 18, and my parents/guardians are aware I am contacting Harmony Hypnosis.I am the parent/guardian of the client.If you are under 18, please affirm that your parents or legal guardians are aware that you are contacting me or that you are in fact the parent or legal guardian of the client in question. If you are above the age of 18, please change your reply in the question above. Terms & Conditions NOTE: Hypnotist/Practitioner are used interchangeably in the following document. I am voluntarily undertaking a program of self-hypnosis under the direction of a trained professional hypnotist, James Hazlerig. I have been advised by James Hazlerig of the scope of hypnosis practice, and I give my full consent to receiving hypnosis sessions from James Hazlerig. I understand that it is up to me to follow instructions to experience hypnosis as I choose. I give James Hazlerig my permission and cooperation to guide me in a hypnotic experience. I understand that hypnosis is an interactive process, that results vary, and that the above-named practitioner may not guarantee results. I understand that hypnosis is not a replacement for medical treatment, psychological or psychiatric services, or counseling. James Hazlerig does not provide therapy nor counseling, and I will regard anything he says as no more than friendly advice. I also understand that the hypnotist is not a medical doctor and does not treat, prescribe for, or diagnose any condition. I understand that the practitioner is a facilitator of hypnosis and is not practicing any other profession that requires a license under the laws of the State of Texas. I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my shoulder(s), hand, wrist, arm, neck, or forehead in order to assist me in relaxation. I give the practitioner permission and consent to do so in order to help me establish a beneficial experience of hypnosis. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability. I have accurately provided background information as requested by the hypnotist. I understand that confidentially regarding my sessions will be honored between James Hazlerig and me. This same confidentially is respected when working with minors under the age of eighteen. I understand that James Hazlerig does not prescribe medication, and I agree to continue taking all medications prescribed by my doctor unless my doctor advises me otherwise. Do you understand and agree to the terms listed above?* Yes Disclosure Statement CONFIDENTIALITY Matters regarding client sessions will be kept confidential except in the following circumstances: The client grants the hypnotist specific permission to release information to a specific individual or agency; child abuse; the client is an imminent danger to self or others; or in the case of the subpoena of records. Any information shared is kept confidential. From time to time, the hypnotist may also consult with other colleagues, but in this circumstance, clients are not identified by name. Checking the box below constitutes giving permission for such consultations. Sessions at Harmony Hypnosis may be video-recorded for archival, security, and ongoing professional development purposes. Video-recordings of sessions will be kept confidential and will be viewed only by James Hazlerig and select professional colleagues he consults with, except in the following circumstances: The client grants the hypnotist specific permission to release information to a specific individual or agency; child abuse; the client is an imminent danger to self or others; or in the case of the subpoena of records. Video-recordings will not be shared publicly for educational, promotional, or any other purposes without the client's express permission. All guarantees of confidentiality remain in place and are extended to professional colleagues with whom James Hazlerig consults. Checking the box below constitutes giving permission to video-record only for archival, security, and ongoing professional development purposes. FEES AND PAYMENTS The charge for hypnosis are listed elsewhere on my website, unless a different package price or discount is arranged. Payment is due prior to the first session, unless other arrangements are made. It is your responsibility to submit to your insurance for any possible reimbursement for services. CANCELLATIONS Since I have reserved our appointment time for you, it is my policy to charge for cancellations received less than 24 hours notice unless we are able to reschedule the appointment within the same week. Insurance companies generally do not reimburse for failed appointments. REPORTS AND PHONE CALLS There is no charge for brief calls. Calls lasting longer than 20 minutes will be charged to the client on a prorated basis. Reports requested by insurance companies, physicians, etc. will not be released without your permission. * Do you accept the confidentiality agreement listed above?* Yes Phone Number*Work NumberMobile NumberEmergency Contact Name*Emergency Contact Phone Number* Client Assessment FormPresenting Issue:*When and under what circumstances did this issue begin?*How has this affected your life?*Has it ever been different?*What specifically about your issue is leading you to seek help now?*Are you on any medication or have you ever been diagnosed with a mental illness?*Do you give James Hazlerig permission to contact your doctor(s) and/or therapist(s)?* Yes No Please provide the name(s) and contact information of your doctor(s) and/or therapist(s), What other kinds of approaches have you tried?What lifestyle or attitude changes have been partially successful?*Do you associate any of these emotions with your issue? Abandonment Boredom Fear Glamour Loneliness Relaxation Satisfaction Anger Depression Femininity Grief Loss Romance Shame Anxiety Embarrassment Frustration Happiness Masculinity Sadness Goals for HypnosisWhat is your 1 month goal regarding this issue(s)?*What is your 6 month goal regarding this issue(s)?*What is your 1 year goal regarding this issue(s)?*What is your 5 year goal regarding this issue(s)?*Additional CommentsAcceptance of Terms* * By selecting this box I am digitally signing this document and confirming that all submitted information is true to the best of my knowledge. How did you hear about Harmony Hypnosis? (Check all that apply.) Print Ad Flyer Web Search Referral from Doctor, Therapist, or Counselor Radio YouTube Video Podcast Word of Mouth Public Presentation or Demonstration Facebook Google+ Other If you chose "Other," please specify.We appreciate your help. If you can recall what search terms you used in the search engine, please tell us what they were.Have you ever tried, experienced, or used any of these techniques? (Please check all that apply.) Hypnosis or Self-Hypnosis Creative or Guided Visualization Meditation or Mindfulness Yoga Brainwave Entrainment (binaural beats, light & sound machines, Audiostrobe, AVS) Biofeedback or Neurofeedback Autogenic Training EMDR Qi Gong Reiki Lucid Dreaming Shamanism If you checked any techniques above, please tell me about your experience.Would you like to receive the monthly Harmony Hypnosis Newsletter, with interesting articles, free recordings, discounts, and updates? Yes, Please! I love discounts and freebies. No, thanks. CAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.