Free Hypnosis Sessions

Are you experiencing stress and anxiety?
Yes No

You must acknowledge that you are experiencing stress and anxiety to continue.

Your answers to all questions below are required, thank you.

1. Do you have a good Internet connection and access to Zoom?
   Yes No

2. Have you ever been hypnotized before? If yes, please describe.
   Yes No

3. Are you, or have you ever been, under any psychiatric care? If yes, please describe.
   Yes No

4. Are you taking any medications including but not limited to anti-depressants? If yes, please describe.
   Yes No

5. Have you ever had an epileptic seizure and/or been diagnosed with epilepsy?
   Yes No
6. Will you be able to respond to our emails and/or phone calls within 48 hours?
   Yes No
7. What is the best day and time to contact you?
   Phone *

   Best Contact Day Monday Tuesday Wednesday Thursday Friday Any Day

   Best Contact Time Morning 10:00 to 12:00 Afternoon 1:00 to 5:00 Evening 6:00 to 8:00 Any Time from 10:00 to 8:00

8. Please provide a detailed paragraph describing why you want Hypnotherapy, what are the symptoms that you are experiencing, as well as when they started and any other relevant information or history.

9. These Free Hypnotherapy Sessions will last approximately 50-75 minutes per session and will be scheduled by mutual convenience between you and the HMI Resident student. Do you agree with these terms?
   Yes No

Yes, I understand this is a free referral service provided by Hypnosis Motivation Institute (HMI), a non-profit corporation. I understand that HMI may be referring me to receive free services from a student/intern or graduate at HMI. I understand this HMI Intern or graduate will be providing me these private sessions as a self-employed independent contractor. As an independent contractor, they are not an employee of HMI and HMI exercises no control over their professional services. By accepting this referral, you agree to hold HMI and/or their agents harmless from any wrong doing, damages or claims of any kind.

While it is the practice of hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court could order disclosure of information learned in therapy. These Zoom sessions may be recorded for quality control and training purposes. Additionally, HMI students/interns may discuss their cases with HMI supervisors for advice and direction in a small group setting with other Interns or graduates. This advice and direction does not constitute control over the student/intern’s private independent practice.

The services provided by a hypnotherapist consist of a behavioral conditioning. The hypnotist will to the best of his or her ability endeavor to accomplish the objectives of the sessions. While hypnosis may be an effective technique for many purposes, the effectiveness may vary from individual to individual and no specific results or progress can be promised or guaranteed.

I understand that these services will be provided via Zoom and that I must have the Zoom App to receive them. I also understand that the agreement to do hypnotherapy is subject to mutual consent between myself and the hypnotherapist providing the services. All Zoom sessions are to be scheduled via Zoom by mutual consent. Failure to show up for a scheduled appointment can result in the end of the services.

I understand that I must provide a quiet, interruption free environment with an adequate Internet connection to participate in these Zoom sessions. These sessions can continue for as long as both parties feel they are valuable and productive. I understand and agree that both parties, myself and the hypnotherapist need to feel that there is a good connection and mutual respect in order for the session to be of value. Either party can decide to discontinue the services at any time.

Yes, I am digitally signing this agreement and have legally accepted the terms and conditions contain herein. This agreement is formally accepted and becomes legally binding once you press the “Submit Registration” button below.