Registration form non-smoking hypnosis

Dear Client,

Your hypnosis appointment is initially marked, but not yet bindingly booked. For the booking I need some important information from you.

Your details, as well as the contents of the session, will of course be treated confidentially. Please fill in all fields and click on “send” at the end of the form. Please make sure that “The message was successfully submitted” is displayed in your browser window at the end. It is advisable to prewrite the longer texts in a word processing program and then copy them over so that the content is not lost in case of technical problems. If you have any problems with sending me the email, there is a Word document at the end of this page, which you can download and send to me by email.

If the information is too sensitive for you to submit online here, you can also print out the form and mail it to my office address or drop it off in person. The practice’s letterbox is located in the entrance area of the medical centre and is only accessible during the day.

You will then receive a binding confirmation of your session by email. If you do not receive an email within two working days, please call me!

Feel free to take some time to fill it out, it’s part of your preparation!

I am looking forward to your registration!

    Non-Smoking Hypnosis

    Medical History Form & Session Preparation

    Please fill out the form completely. Your information helps to prepare the session in the best possible way.

    Appointment & Contact Details










    General Information

    Existing pregnancy*

    I have already experienced hypnosis*

    Physical Illnesses

    Diseases: Epilepsy*

    Strong asthma*

    Other seizure disorders*

    Persistent severe pain*

    Significant circulatory problems*

    Infectious diseases, e.g. hepatitis B/C*

    Heart diseases*

    Problems with shoulders, arms or hands*

    Other serious physical illness*

    Physical or mental disability*


    Mental Health & Treatments

    In treatment with psychotherapists*

    Under treatment by psychiatrist or neurologist*

    I am currently taking antidepressants or neuroleptics*

    Severe mental illness / psychosis*

    ADD, ADHD or HKS*





    Addictions & Consumption

    Dependence on medications*

    Alcohol dependence*

    Drug addiction, except tobacco*

    Cannabis use*

    Experience with psychoactive drugs, e.g. LSD*

    Session Preparation






    Further Information

    How did you find out about Kiez Hypnosis?*

    What tea would you like to drink in the session?*

    AGB Kiez Hypnosis
    General terms and conditions of business

    Download

    Registration form non-smokers
    Registration form.docx
    Download

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