Name *

First Name

Last Name

Permission to communicate with your doctor? *

Yes

No

Are you currently receiving care from any other Health Professional? *

Yes

No

Have you ever been hypnotised before? *

Yes

No

Are you wearing contact lenses? *

Yes

No

Are you taking any medication? *

Yes

No

Are you pregnant? *

Yes

No

Do you have Epilepsy? *

Yes

No

I agree to be hypnotised and this consent applies until revoked by me *

Yes

No

Acknowledgement *

I agree that the information provided is correct. I agree that the therapist shall not be held responsible or liable in any way, for any unforeseen outcome(s) from this or any subsequent hypnosis sessions and I understand that there are no guarantees relating to the outcome(s) of this, or any subsequent hypnosis sessions that the therapist conducts with me. I understand that I may require more than one hypnotherapy session. I understand that the therapist does not treat, prescribe for, or diagnose any illness, disease, or any other physical or mental disorder, injury, or condition. (Nothing said or done by the therapist will be construed as such). I further understand that the therapist is not attempting to practice medicine, psychology, counselling, or any other profession requiring a licence under New Zealand Law. I understand that, for the safety of the therapist or myself as the client, I may be referred on to another practitioner for support. If I choose to make an audio recording of any session, it is for my personal use only, and I agree not to share it on any platform or with any other person. I will not make a video recording of any session. I give my permission for relevant information about my medical condition/s and/or treatments to be shared with other Wellness New Zealand practitioners if I choose to seek complimentary treatment from those practitioners.

I agree