Registration Form - Anxiety Treatment in Huntsville Alabama

Date*

Name*

First Last

Address (fill all fields)*

Street Address Address Line 2 City State ZIP Code

Tel: Home

Cell*

Work

Email*

Gender:*

M
F

1st Language:

Date of Birth:*

Marital Status:

Occupation:

In case of emergency contact:

Relationship:

Do you have children?

Yes
No

Ages:

Do they live at home?

Yes
No

How did you hear about Charles Beeson, CHt., Hypnotherapy ?

Do you have a Yelp account?

Yes
No

Have you been under a doctor’s care (physical or psychological) during the past year ?

Yes
No

If so, please describe

Have you ever been treated for an emotional condition ?

Yes
No

If so, please describe

Have you had any prolonged illness ?

Yes
No

If so, what and when ?

What is your PRIMARY goal in using hypnotherapy?*

Select From Drop-down list

What is your SECONDARY goal in using hypnotherapy?*

Select From Drop-down list

Explain Your Goal/Objective

When did it begin?

Was there a traumatic event or illness preceding the onset of this condition ?

Yes
No

Describe:

Any previous efforts to solve this problem ?

Yes
No

If so, how?

What were the results ?

Are you currently undergoing medical or psychological treatment for the above condition ?

Yes
No

If so, what kind of treatment and by whom ?

Medications:

Allergies:

Describe any special prescribed diet:

Do you have any exercise limitations?

Name of Primary Physician:

City

Name of MD Specialist :

Specialty :

City :

Do you have any fears or phobias ?

Yes
No

Describe fear:

Describe :

Have you ever used hypnotherapy before?*

Yes
No

Terms of Therapy Treatment Sessions

I agree to Terms of Therapy Treatment Sessions

Terms of Hypnotherapy Sessions:

1. There are no guarantees of results.

2. A 24-Hour notice is required for appointment change or cancellation or full charge will be incurred.

3. There are no refunds for prepaid, discounted programs

I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis and stress reduction processes and techniques. I understand that the therapy I am receiving is not a substitute for normal medical care and I have been advised to discuss this therapy with any doctor who is taking care of me now or in the future. Additionally, I should continue my present medical treatment and consult with my regular doctor for treatment of any old or new illness.

I understand that Charles R. Beeson, CHt., is a legal Alternative/Complementary Healthcare/ Wellness Provider; not a Licensed Physician or Psychologist. His self regulated holistic treatments and specialties do not require state licensing and the client-centered disciplines, philosophy, education, experience & certification in hypnotherapy, allow him to assess, advise & assist me to: achieve personal goals, change behaviors, alleviate emotional problems, manage symptoms of various medical complaints, and enhance motivation & self confidence.

I also understand that Charles R. Beeson, CHt., has OVER 100,000 hours of training and experience in hypnosis, hypnotherapy and NLP.

I have read and understand the InstaCalm™ Best Results Guarantee.

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