Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone *

(###)

###

####

Have You Ever Attempted Suicide? *

No

Yes

Are You Currently Having Suicidal Thoughts? *

No

Yes

Are You Currently Taking Medication?

No

Yes

Do You Use Alcohol? *

No

Yes

Do You Use Other Drugs? *

No

Yes

Date *

MM

DD

YYYY

ONLINE Zoom Conferencing Sessions *

• There are potential benefits and risks of video-conferencing (e.g. limits to client confidentiality) that differ from in-person sessions. • Confidentiality still applies for on line services, and nobody will record the session without the permission from both the client and therapist. • We agree to use the video-conferencing Zoom platform selected for our virtual sessions, and the therapist will explain how to use it. • You need to use a computer, or smartphone during the session. • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • It is important to be on time. If you need to cancel or change your online appointment, you must notify the therapist in advance by phone or email. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. • If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in the online sessions. • You are responsible for full payment. Payments are made through the PayPal site. Use this email for payment: • holly@hypnotherapytraining.com

I Have Read, Understand and Accept This Disclosure

Client *

First Name

Last Name