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One-On-One Appointment with Dr. Richard Nongard
Client Information Form

Please take a few minutes to complete this form, it will help me get to know a few things about you before our meeting. I am sure there are many other things you would like to discuss, and there will be ample time in our session for this.

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Date

MM slash DD slash YYYY

Name

First Last

Preferred Contact Telephone #

Age

Gender

Male

Female

Date Of Birth:

MM slash DD slash YYYY

What do you want to accomplish with hypnosis in your session:

What is your prior experience with hypnosis:

What are your beliefs about hypnosis?

I think it can help me

I will try it and see what happens

I am a skeptic

What are your three biggest personal strengths?

How much do you currently weight?

What is your target weight?

Do you drink alcohol?

Never

Once a month

Once a week

A few times a week

Daily

Do you smoke cigarettes?

Never

Former Smoker

Yes, I am current smoker

If so, When did you quit:

If so, How many cigarettes per day:

Your age when you started smoking?

Do you use marijuana?

Yes

If so, How often:

Do you have sleep difficulties?

Rarely

I don't get enough sleep

I have trouble falling asleep

I have trouble staying asleep

I sleep too much

Eating Patterns:

I am on a special diet

I eat mostly healthy foods

I don't eat regularly

I overeat

I do not eat enough

I binge eat

I purge myself when full

I snack too often

Specify

Exercise Patterns:

I work out

I exercise occasionally

I do not get enough exercise

I have a health condition that limits my ability to exercise

Specify

In my personal relationships, I am:

Unsatisfied

Sometimes satisfied

Mostly satisfied

I am very happy with my relationships with others

What do you do to handle tension and stress?

What do you do for fun?

What are your hobbies?

What do you want to accomplish with hypnosis?

Is there anything else you think would be helpful for me to know before our first meeting?

I agree to engage in the process on non-therapeutic hypnosis with Richard Nongard. I understand that I will have all choices at all times and can start and end the process at anytime, even during my session. The services I render are held out to the public as non-therapeutic hypnotism, defined as the learning of self-hypnosis to induce positive thinking, creating commitment to change, and to learning the techniques of self-hypnosis to produce self-control over physical experiences and emotional awareness. I do not represent my services as any form of health care or psychotherapy, and I may make no health benefit claims for my services. I agree to continue medication as prescribed by my attending physicians and understand that hypnotherapy is not a substitute for medical care. I understand a hypnotist neither diagnosis nor treats any medical or mental health condition, instead offering tools of self-discovery and awareness to compliment any medical treatment prescribed by a physician. If any medical symptoms progress or become acute I agree to seek medical attention from a licensed healthcare provider. In the event of a medical emergency or if I feel suicidal, I will call 911 or other emergency help. I understand that the methods of hypnosis include relaxation, breath work, creative visualization, positive affirmation, mindfulness, self-awareness development and other techniques and may produce physical and emotional responses. I agree to inform my hypnotist of any adverse feelings or experiences related to this process, at the time of my awareness of them. I have been informed as to the limits of hypnosis effectiveness and offered referral to other providers of alternative approaches to problem solving. I am over age 18, and consent to hypnosis services offered by Richard Nongard. Please sign (print) your name in agreement:*

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One-On-One Appointment with Dr. Richard NongardClient Information Form

Please take a few minutes to complete this form, it will help me get to know a few things about you before our meeting. I am sure there are many other things you would like to discuss, and there will be ample time in our session for this.

Get Your Photography Portfolio Started Now

One-On-One Appointment with Dr. Richard Nongard
Client Information Form