Stop Smoking Intake Form

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Your success is our #1 priority. Help us to help you achieve that success by filling out this questionnaire as completely as possible.

Your Name*

Date*

Address*

City*

Postal Code*

Email*

Home #

Work #

Cell #

Height*

Weight*

Age*

Sex*

Marital Status*

Education*

Major*

Occupation*

Favourite Hobbies*

Do you enjoy your work?*

Do you feel stress (explain)?*

Are you currently taking any medication? (please list)*

Physician’s name and office?*

Can we communicate with your physician regarding your program?*

Do you have light sensitive epilepsy?*

Do you exercise?*

How often?*

What Type?*

What do you expect from hypnosis?*

Have you ever been hypnotized before?*

Results?*

Why do you choose us for hypnosis?*

How did you hear about us? (Please be specific)*

If you were referred by one of our former clients, please tell us who we can send a thank you note to:

How long have you been smoking?*

How much do you smoke?*

Have you tried to stop before?*

How many times?*

What methods failed to help you stop smoking?*

Are you embarrassed by your need for a cigarette?*

Is your smoking making you physically uncomfortable?*

Does your smoking limit you or your activities?*

Do you feel your smoking controls you?*

Is successfully quitting smoking a top priority? (explain)*

What new activities will you become involved in after you stop smoking?*

Did you know hypnosis is 100% safe?*

Do other family members smoke?*

Does your family support your stop smoking efforts?*

Is your family excited about your stopping smoking with hypnosis?*

Do you feel tired, run down and out of energy?*

Can you remember when you did not smoke?*

What do you remember about not smoking?*

Has smoking caused you pain or suffering yet? (Describe physical or emotional)*

What is the number one reason why you want to stop smoking?*

Choose the most important element in deciding to use our services (CHOOSE ONE):*

Effectiveness (your results)

Time (how fast you get results)

Service (how we respond to your needs)

Affordable (what we charge)

Please certify that the information you have provided in this form is true and complete:

I certify that the information I have provided in this form is true and complete. As a client of Fraser Valley Hypnosis, my acceptance into a self-hypnosis program and my ability to receive self-hypnosis services or training depends upon my informed consent, full understanding and agreement to the following:

All hypnosis is self-hypnosis. The client is directly responsible for learning to become hypnotized by following the specific directions and instructions of the hypnotist.

I understand that the training at Fraser Valley Hypnosis is for self-hypnosis and educational purposes only. As trainers, our hypnotist and staff are responsible for providing training needed for client to learn the skill of hypnosis to achieve the goal they sought help for (for example: weight loss, stress management, stop smoking, pain management). The Centre does not diagnose or treat medical conditions. The self-hypnosis training I receive is not therapy, and it is not meant as a replacement for any other intervention.

All trainers who work with clients at Fraser Valley Hypnosis are either fully certified hypnotists, or student hypnotists-in-training under the direct supervision and oversight of the certified hypnotist. The purpose of self-hypnosis training is for self-improvement and for personal use of the client only. The self-hypnosis training is not intended for any other use by the client, or for use on any other person.

Fraser Valley Hypnosis uses light & sound technology to enhance my hypnotic experience. I understand that I can refuse or stop the light & sound technology at any time for any reason.

I am aware that all rooms in Fraser Valley Hypnosis are monitored by video and audio surveillance for my protection, and for quality assurance and training purposes. The audio and video files are kept strictly confidential.

It is the responsibility of the client to notify the hypnotist if the client has any concerns, problems, or issues of any kind with the training they received. At no time will any client be made to do anything against their will or personal value system Fraser Valley Hypnosis reserves the right to terminate a client’s program if it becomes evident that the client requires a different type of help.

I understand Fraser Valley Hypnosis only takes clients that are 100% committed to achieving their goals. I understand it is my responsibility to take actions to achieve my goals and that there are No Refunds because I have to see the whole program through to make the changes needed.

Changes happen over time and I commit to the time needed, I am sincere about wanting to reach my goal. The client has the right to confidentiality, except as prohibited by British Columbia and/or the Canadian Law.

I, hereby release and forever indemnify Angela Nyhuis, Fraser Valley Hypnosis and National School of Hypnosis or any one working for her or assisting her in her practice or any organizations associated with her, and shall not make any claim against the above referred individuals or organizations, for any injuries or other damages I suffer arising from the self- hypnosis sessions, instructions, programs, teaching of relaxation, assistance in specific goal achievements or any other such activities in which I participate or follow their advice, even if such damages or injuries arise out of their negligence.

I have read, understand and agree to the contents of this waiver.

Type Your Name:*

Date*

Yes, I would like to receive valuable newsletters and special promotional offers from Fraser Valley Hypnosis. You can reach me with the email and address on this intake.

YES

Yes, I would like to receive valuable newsletters and special promotional offers from National School of Hypnosis. You can reach me with the email and address on this intake.

YES

Yes, I would like a FREE 3 month Associate Membership to the Master Hypnotist Society for valuable newsletters, product catalogs, special offers and event announcements from the Master Hypnotist Society. You can reach me with the email and address on this intake form.

YES

By submitting this form you agree to all of the above*

YES

Stop Smoking Intake Form

Stop Smoking Intake Form

Please certify that the information you have provided in this form is true and complete:

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