Name
*
First Name
Last Name
Preferred Name
Age
Telephone Number
Email
*
Address
Emergency Contact
*
Emergency Contact Number
*
Relationship Status
Health Problems (List problems)
Tick any issues below that relate to you
Medications Taken
Describe your main concerns/issues you would like dealt with?
*
What are the symptoms, triggers, habits related to this issue?
*
How would you describe your childhood between the ages of 5 to 12 years old?
*
What outcome do you really want from this session?
*
What would your life be without these issues? (Describe vividly what you want to see/hear/feel at the end of your transformation?)
*
On a scale of 1 - 10, how ready are you for this transformation?
*
SCOPE OF PRACTICE I understand that Linda Lutey is not a licenced physician, psychologist, or medical practitioner or any kind that hypnosis should not be considered a replacement for the advice and/or services, over psychiatrist, a psychologist, or doctor. By choosing to partake in your virtual therapy, you confirm that you do not have Epilepsy, or have not been diagnosed as having a psychotic illness or should not enter into hypnosis due to current medical issues that would put you at risk during the duration of your session(s) . Or you have emailed your GP’s referral memo to llinnerhealing@hotmail.com. Linda Lutey Inner Healing has taken due care and attention with the information provided at this therapy session and information is given in good faith. The information given is not intended to constitute medical advice. Always consult your GP before changing medications and evaluating treatment alternatives. Do not make adjustments to any prescribed medication without the approval of your doctor. You also understand that you will be regressed back to scenes in your childhood in order to work on memories and events that are the root, the cause, the reason for your presenting issue/problem. You also agree to the therapist giving commands relevant to hypnosis techniques and suggestions an understand that this is done only with good intentions towards you the client.
*
The information I have given here to the best of my knowledge is full and correct. I undertake Therapy on the understanding that is a collaborative process, and that process depends in part upon my own motivation and participation. I accept that all appointments not cancelled within 48 hours will be charged for in full and outstanding instalment arrangements still stand and until fulfilment where applicable.
*
By submitting my Full Name, I agree to all the above terms and conditions and this agreement is now valid.
*
Date of submitting this declaration:
*
MM
DD
YYYY