You’re Two Steps Away from Your First Session

Pick a time that works for you, fill out an intake form, and we’ll meet via Zoom. Lets start the process of positive change.

Step 1: Choose Your Time

All sessions are virtual via Zoom. Pick a date and time below that works for your schedule.

Step 2: Intake Form

Questions that will help me tailor our session to your needs.

Client Intake Form

Confidentiality: Your information is kept confidential except where required by law.
Hypnotherapy Disclaimer: Hypnotherapy is not a substitute for medical or psychological diagnosis and treatment. Please consult your healthcare provider for concerns outside the scope of hypnotherapy.

First Name (required)

Last Name (required)

Email Address (required)

Phone Number (required)

Date of Birth (required)

Pronouns

City

State/Province

Country

Medical & Mental Health History

Do you have any current medical conditions we should be aware of?

Are you currently taking any medications?

Have you been diagnosed with any mental health conditions?

Are you currently working with a therapist or counselor?

YesNo

Additional Information

How did you hear about me?

If referred by someone, please provide their name:

Is there anything else you’d like us to know?

Consent & Agreement

I understand that hypnotherapy is not a substitute for medical or psychological treatment, and I have consulted or will consult my healthcare provider as needed.

I consent to participating in hypnotherapy sessions and understand I can withdraw consent at any time.

I acknowledge that my information will be kept confidential except where required by law.