Online Hypnotherapy Waiver NAME EMAIL ADDRESS PHONE NUMBER HAVE YOU EXPERIENCED HYPNOTHERAPY PREVIOUSLY? IF SO, HOW WAS YOUR EXPERIENCE? WHAT IS YOUR MAIN REASON FOR BOOKING A SESSION? DO YOU HAVE ANY PHYSICAL OR MENTAL CONDITIONS THAT YOU THINK I SHOULD KNOW ABOUT? IS THERE ANYTHING ELSE THAT YOU WOULD LIKE TO SHARE ABOUT THE ISSUES THAT YOU WOULD LIKE TO WORK ON, OR ANY QUESTIONS FOR ME? BY SIGNING THIS FORM, I AGREE TO PARTICIPATE IN COUNSELING HYPNOTHERAPY. I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR MY OWN EXPERIENCE, AND I WAIVE TIINA KIVINEN OF ANY LIABILITY. I AGREE THAT HYPNOTHERAPY IS NOT INTENDED TO REPLACE THE TREATMENT OF A DOCTOR OR PHYSCHOLOGIST WHERE NEEDED. SIGNATURE DATE
