Client History Form
Please, fill out what applies to you
Please provide your name:
Please provide your address:
Number of children?
Reason for coming for Hypnosis/Guided Imagery?
Any previous efforts to solve the above problem?
Are you presently undergoing Medical or Psychological treatment for the above problem?
How long have you been receiving treatment?
What is your physicians name?
Are you currently on any medication for the above problem or any other condition?
Please specify what medication you are taking?
What are the affects of the medication?
Please indicate where you found the information for my services?
Please Read the following
Please remove contact lenses before the
session. They may inhibit your ability to completely relax. Please use
the bathroom before the session as that may also inhibit relaxation.
Please read the statement and if you agree
please sign the bottom signature section.
I hereby authorize, Wally Muller, to
hypnotize or use guided imagery with me for the purposes outlined in
(reasons for coming for hypnosis/guided imagery) and for any future
purposes I request.
I understand that the results of my
hypnosis/guided imagery depend greatly on my own ability to relax and
the desire to create change.
I understand that the result(s) achieved
from my session(s) depends greatly on my serious participation.
I understand that hypnosis/guided imagery is
not a medical or psychological procedure.
I am aware and trust that Wally Muller will
do everything reasonable in his power to ensure my success.
understand that the hypnosis/guided
imagery sessions will be audio
or video recorded for any
follow up session's, continuity or
training and all sessions are
Wally Muller does not offer any guaranties
as to the success of my sessions(s).