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Health History

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Hypno Questionnaire

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  • Date Format: MM slash DD slash YYYY

Informed Consent - COVID

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  • Informed Consent

    This document contains important information about our decision (yours and mine) to resume inperson services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.

    Decision to Meet Face-to-Face

    We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via zoom! You understand that, if I believe it is necessary, I may determine that we return to an online platform for everyone’s well-being. If you decide at any time that you would feel safer staying with, or returning to, remote services, I will respect that decision, as long as it is feasible and clinically appropriate. Fees for service will remain the same unless otherwise discussed and agreed upon.

    Risks of Opting for In-Person Services

    You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.

    Your Responsibility to Minimize Your Exposure

    To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, my office mates and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to remote sessions.

    Initial each to indicate that you understand and agree to these actions:
  • I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

    If You or I Are Sick

    You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services remotely as appropriate.

    If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

    Your Confidentiality in the Case of Infection

    If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.

    Informed Consent

    This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.

    Your signature below shows that you agree to these terms and conditions.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Office Safety Precautions in Effect During the Pandemic My office is taking the following precautions to protect our patients and help slow the spread of the coronavirus.
    • Office seating in the waiting room and in therapy rooms has been arranged for appropriate physical distancing.
    • I will wear a plastic face shield or mask.
    • Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
    • We schedule appointments at specific intervals to minimize the number of people in the waiting room.
    • We ask all patients to wait in their cars or outside until no earlier than 5 minutes before their appointment times.
    • Credit card pads, pens and other areas that are commonly touched are thoroughly sanitized after each use.
    • Physical contact is not permitted.
    • Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
    • Common areas are thoroughly disinfected at the end of each day and wiped down between clients.

Hypnosis – Expectations and Misconceptions

When the word hypnosis is mentioned in conversation, the reactions are usually varied.  Responses range from disbelief to mortal terror and even laughter.  On the other hand, some people believe that hypnosis can work miracles!  These are all based on misconceptions and misunderstandings.

A simple definition of hypnosis is ‘a state of increased suggestibility and concentration’.  First of all, You WILL NOT GO TO SLEEP or lose touch with reality.  Quite the contrary, in most cases you will be quite aware of what is being said and what is happening around you.  On awakening, some people even will say that they were not hypnotized since they were aware of everything or felt unaffected by the hypnotist.  The lack of consciousness or amnesia that some people anticipate is not experienced by most people.  Even if the perception is that the trance state was very light, the suggestions which have been made to them in most cases will have an influence, unless the subject deliberately sets out to block or prove that they will not work.

It is perfectly normal to hear external noises, maintain a rapport with your hypnotist, and be able to recall everything that went on during your session.  You may feel no different than you did before your session (though most people report being very relaxed), but the effects will be there.  To quote the June 1977 issue of Psychology Today:

People who are hypnotized for the first time are frequently disappointed to find that they experience nothing overwhelming.  They feel mildly relaxed, but they remain in touch with reality and in control of their thoughts.  They may discover that the hypnotists’ suggestions are quite resistible.  Contrary to what most people believe, a person under hypnosis needs not fall asleep, or lose contact with his surroundings or relinquish his will.  He is often able to recall everything that happened during the trance and will act perfectly normal.

Physicians, Psychologists, and Hypnotherapists have used hypnosis as a valuable tool in solving such problems as sleep disturbance, concentration, and memory, fears, and phobias, as well as control of pain and asthma.  It has also been helpful in changing habits and addictions as smoking, overeating, alcohol and substance abuse, and much more.

You will find hypnosis to be a very relaxing and enjoyable experience.  Keep in mind that all hypnosis is self-hypnosis, you are in control, your hypnotist is just a guide! Without your cooperation, it may very well be ineffective.  During your initial interview with your hypnotist be sure and ask any questions and express any concerns.

“The easier you can make it inside your head, the easier it will make things outside your head.” ~Richard Bandler