Participant Information

Name

First

Last

Date of Birth

Have in ever

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Email

Emergency Contact Number

Have you ever been diagnosed with a mental illness?

Yes
No

Are you on any medication?

Yes
No

If yes, list the medications?

List any other Specialists / Therapists you are currently under the care of?

List the main areas / symptoms of disruption in your life?

Have you had Hypnotherapy before?

Yes
No

Describe your quality of sleep/ relaxation?

Very good
Good
Average
Poor

Have you ever experienced any of the following?

Cancellation Policy

I agree to give a minimum of 24 hours notice for all cancellations and understand that failure to do so will result in the full fee being forfeited.

Release of Liability & Terms of Service

HYPNOTHERAPY SERVICE LIABILITY RELEASE AND WAIVER I hereby agree to the following terms and conditions in relation to hypnotherapy services provided by Trish Wallace at Future Mind Garden Hypnotherapy. VOLUNTARY PARTICIPATION I acknowledge that I am participating in hypnotherapy sessions voluntarily and of my own free will. I understand that hypnotherapy is a collaborative process, and its success depends on my willingness to participate and engage in the process. UNDERSTANDING OF SERVICES I understand that: Hypnotherapy is not a replacement for medical, psychiatric, or psychological treatment The practitioner does not diagnose conditions, prescribe medications, or interfere with existing medical treatments Results may vary, and no specific outcomes are guaranteed Hypnotherapy is a complementary therapy designed to support overall wellbeing CLIENT DISCLOSURE I agree to: Provide accurate information about my physical and mental health history Inform the practitioner of any medical conditions or medications Notify the practitioner of any changes in my health status Disclose if I am currently under the care of a mental health professional PRACTITIONER QUALIFICATIONS I acknowledge that Trish Wallace is a qualified hypnotherapist with extensive experience in both hypnotherapy and float therapy industries. I understand that she combines various modalities including Hypnotherapy, NLP, and unconscious pattern integration. CONFIDENTIALITY I understand that all information shared during sessions will be kept confidential, except: Where required by law Where there is risk of harm to self or others Where professional consultation is required Where written permission is provided by the client RECORDING AND NOTES I understand that sessions may be documented for therapeutic purposes, and I consent to the practitioner maintaining appropriate clinical notes. ASSUMPTION OF RISK I understand and accept that: Hypnotherapy may bring up emotional or psychological material Changes in behaviors, beliefs, or emotions may occur The practitioner cannot guarantee specific results RELEASE OF LIABILITY I hereby release Trish Wallace and Future Mind Garden Hypnotherapy from any liability, claims, or actions arising from my participation in hypnotherapy sessions, except in cases of gross negligence or professional misconduct. RIGHT TO TERMINATE I understand that either party may terminate the therapeutic relationship at any time, and that I have the right to refuse any suggestions or procedures during sessions. PAYMENT AND CANCELLATION I agree to comply with the established payment and cancellation policies as provided separately. By signing below, I acknowledge that I have read, understood, and agree to all the terms and conditions stated above.

Signature

Clear Signature

Date of Signature