Consent FormPlease complete and submit this form before your initial appointment. Complete consent form Consent form Name * First Name Last Name Date of birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact * Occupation How did you hear about us? Reasons for your visit? Goals? * What are your expectations from hypnosis? Have you been hypnotized before? * Yes No If yes, please provide some background Have you previously been treated for any conditions? Yes No If yes, please provide some background Are you currently in treatment for any conditions? Yes No If yes, please provide details Your Doctor's name Your Doctor's phone number Have you previously taken any medications? Yes No If yes, please provide details Are you currently taking any medications? Yes No If yes, please provide details DISCLOSURE, INDEMNITY & CONSENT * Trance4orm Services Inc. and/or each of its directors, employees and contractors ("Trance4orm") do not treat, prescribe for or diagnose any condition. Trance4orm is a properly trained facilitator of hypnosis and not practicing any other profession that requires a license under the laws and regulations of Canada and Australia. The provision of hypnosis services entails the collection and recording of personal information relevant to your current situation. Any personal information gathered, recorded and/or filed by Trance4orm is available upon your request and shall remain confidential and secure except if it is subpoenaed by a court of law. You give permission for Trance4orm to discuss your case with a physician/health professional, parent or another person, if appropriate. Hypnosis is not a substitute for medical and psychological treatment. Trance4orm provides hypnosis services within the guidelines of the laws and regulations of Canada and Australia. You hereby agree to indemnify and hold Trance4form harmless from and against any and all expenses, losses, claims, actions, damages or liabilities that arise out of or are based, directly or indirectly, upon the performance of hypnosis services rendered to you by Trance4orm. However, this indemnity shall not apply to the extent that a court of competent jurisdiction in a final judgment that has become non-appealable shall determine that: (i) Trance4orm has been negligent, exercised bad faith, contravened any applicable law, was dishonest or acted fraudulently in the course of such performance; and (ii) the expenses, losses, claims, actions, damages or liabilities, as to which indemnification is claimed, were caused by the acts or omissions referred to in (i). You understand that you will be charged for any session cancelled with less than 24 hour notification. You also understand that Trance4orm offers no refunds and only credit for any unused sessions. I have read and acknowledged the disclosure, indemnity and consent statement. * I have no physical or mental conditions that would make it inappropriate or inadvisable to be hypnotized; Or I have provided a referral from my treating physician/health professional to use hypnosis as an adjunct for my condition(s). * I confirm that the information provided to Trance4orm in this form is true, complete and accurate. I have read, understand and accept this Disclosure, Indemnity & Consent and I expressly consent to be hypnotized for the purpose of helping me with the reason(s)/goal(s) that I have described above and/or otherwise communicated to Trance4orm. Confirm Thank you! Your consent form has been received.
