CLICK HERE FOR IMPORTANT APPOINTMENT POLICIES

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Hypnosis
Energy Healing & Classes
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Forms

Hope Hypnosis And Holistic Center

Call us Today:

(609) 242-3900

hopehypnosis@aol.com

465 Route 9, Waretown, New Jersey 08758

Subscribe to Our Newsletter Subscribe to Mary's YouTube Channel Make a Payment SPIRITUAL JOURNEY METAPHYSICAL GIFTS

In-Person, Telephone, Virtual:

Hypnosis, Readings, Reiki Healings & Classes

Hope Hypnosis And Holistic Center

Call us Today:

(609) 242-3900

hopehypnosis@aol.com

465 Route 9, Waretown, New Jersey 08758

CLICK HERE FOR IMPORTANT APPOINTMENT POLICIES

Subscribe to Our Newsletter Subscribe to Mary's YouTube Channel Make a Payment SPIRITUAL JOURNEY METAPHYSICAL GIFTS

In-Person, Telephone, Virtual:

Hypnosis, Readings, Reiki Healings & Classes

Home
Hypnosis
Energy Healing & Classes
Psychic Astrology/Angel Reading
- Monthly Horoscope
- All About Angels
Spiritual Journey Metaphysical Gifts
Forms

Forms must be filled out at time of booking with the exception of Covid-19 Waiver which must be filled out within 24 hours of appointment.

HYPNOSIS FORM

Hypnosis Form

First Name:

Last Name:

Date of Birth:

Phone:

Work Phone:

Address:

City:

State:

Zip Code:

E-Mail Address:

Marital Status:

M

D

S

W

Children?

May I send you workshop information/newsletter?

Yes

No

Occupation

Reason for Visit:

Describe any major illness or chronic health problems either past or present:

What, if any, medications are you currently taking?

Please choose Yes or No to the following questions:

Please choose Yes or No to the following questions:

Have you ever been treated for emotion problems?

Yes

No

If yes, are you currently receiving treatment or counseling?

Yes

No

If so, by whom?

Have you been under a physicians care in the past year?

Yes

No

Name of Dr. and Address:

Have you ever been treated for:

Heart

Diabetes

Epilepsy

Pain

None

May I contact your physician or psychiatric professional?

Are you using any other modalities in your healing?

Yes

No

If so '' what?

How did you hear about me?

Yellow Pages

Newspaper

Advertisement

Referral

None

Internet

If so, by whom?

RELEASE

I understand that my success depends on my commitment to improving the situation that brings me here. I understand that Mary Silvernail is not diagnosing; prescribing for, or treating any physical or mental ailment and do not hold her responsible for them. I release the hypnocounselor from any liability whatsoever regarding, session. I agree to inform Mary Silvernail of all physical or mental conditions which might affect her work. I understand that our sessions may involve healing touch. I authorize this release form to apply to all future appointments as well. I agree to pay in full for any appointment canceled with less than 24 hours notice, emergency situations excluded. Deposits are not refundable and a new deposit after the first rescheduled appointment will be requested. No refunds

Signature

Date

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We will get back to you as soon as possible.

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Hypnosis
Energy Healing & Classes
Psychic Astrology/Angel Reading
- Monthly Horoscope
- All About Angels
Spiritual Journey Metaphysical Gifts
Forms

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Contact Information

hopehypnosis@aol.com

(609) 242-3900

465 Route 9, Waretown, New Jersey 08758

Board Certified: Intnl. Medical & Dental Hypnotherapists Assn., Intnl. Assn. Of Counselors & Therapists, American Board of Hypnotherapy.

No refunds

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