R4 Hypnotherapy Intake Form

Full Name

Occupation

Emergency Contact Name & Number

Do you have any disabilities?

Are you on any treatments, remedies, or medications?

Please list your doctor, medical team, other practicioner(s), and/or specialist team members, along with their contact information.

Informed Consent

I authorize Camille O’Donoghue to use techniques outlined on this website, including hypnosis during sessions for the purposes of treatment.

I am aware that these techniques are not offered as a substitute for medical diagnosis or care.

I understand that the results of my sessions greatly depend on my participation. There are no guarantees however Camille will do everything in her power to ensure my success.

I understand Client confidentiality can be broken if there is a serious risk of harm to myself or others.

Payment is to be made in full prior to any session.

I understand that if I cancel or reschedule an appointment, I will respectfully give at least 24hrs hours notice. If I fail to do this, I understand that a cancellation fee of full amount will apply.

Thank you for completing and sending your intake form.

Intake Form

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