Please enable JavaScript in your browser to complete this form.Name *FirstLastDate: *Full Address (house/apt#, street, city, state, zip) *Phone# + yes / no if text-messaging is preferred at this number *Email *Name of Emergency Contact & Phone#: *Note: this person will be contacted if I am unable to reach you, directly, as well as in case of an emergency and in regard to any issues of nonpayment. Are you currently working with: *N/AMental Health ProfessionalPrimary Care PhysicianOther Health Care ProviderI am interested in: *ConsultationHypnosisCoachingCombination of Hypnosis & CoachingBecoming Certified as a Professional HypnotistBecoming Certified as a Rejuvenation SpecialistI prefer to have: *Private / In Office SessionsPrivate / Audio SessionsPrivate / Video SessionsA combination of in-office, audio, and or video sessionsGroup / In Office Sessions with friends/familyLarge or Employee Group Sessions{Large Group sessions would consist of 4+ individuals for the same topic / Employee Group sessions are 10+ individuals for business employees for same topic}If you prefer Large or Employee Group Sessions, what is the topic?N/ASmoking CessationWeight ManagementTime Management ProductionStress / AnxietyI have: *not been hypnotized beforepreviously been hypnotizedDo you think hypnosis will help you? *100% YesNot sureIt's my last hope / have tried everything elseNot reallyDo you habitually use: *N/AAlcoholMarijuanaOther drugsShoppingGamblingAbnormal Food / EatingWhat topic / subject will we be working on? *Check all other topics that apply: *Insomnia / other sleep disturbanceFears / PhobiasAnxiety / StressPTSD / TraumaWeight Loss / GainEating Disorder Smoking / Tobacco or VapeMigraines / Recurring HeadachesStutteringLow Confidence / Self-EsteemUncontrolled AngerSeizuresSelf-Sabotage / Negative Self-Belief'sNarcolepsy ADD / ADHDHoarding Motivation OtherDescribe Other:What helps you to relax when you are stressed out or upset? *MusicPetsDrivingFishing / HuntingExercizingMindfulness Techniques Creating Art (drawing, painting, building, etc)CleaningQuiet / Private TimeOtherDescribe Other: Do you give Eva Wells or Sue Ulm / 1st Choice Hypnosis permission to hypnotize you for the agreed upon topics? *YesNoPlease explain any concerns or questions you may have?Service Agreement *I agree to commit and follow through with suggestions, scheduling, etc.Due to the natural ability of the mind, any final outcome is based upon your own willingness and commitment to follow through with suggestions provided, combined with unknown various possible outside influences. Therefore, although I do and will pull out every option possible within the techniques at my disposal, to provide you with complete success, there is no possible way to guarantee any service provided will be successful. By purchasing or participating in any service provided, you are accepting full and complete responsibility with the information included herein, in regard to your rate of success, or lack there-of. Additionally, you fully agree to and understand that Eva Wells / Sue Ulm / 1st Choice Hypnosis is in no way liable for any loss, accident, injury, or complication, regardless of cause or situation. Length of Package Validity *I agree to this time frameI understand that any program that I purchase and begin is valid and must be completed within 90 calendar days from the original date of purchase unless otherwise previously agreed upon. Any unused appointments after that date will become null and void, unless otherwise previously agreed upon and put in writing by Eva Wells or Sue Ulm / 1st Choice Hypnosis.Disclaimer *I agree that I am willing working with a Hypnotist - not a mental or medical health professionalHypnosis techniques are not in any way meant as a substitute for standard medical, psychiatric, or psychological treatment. All content on this website, or in any other format, is for informational purposes only. It is not intended to diagnose, treat, or act as a substitute for professional medical advice. Any changes to your current treatment should always be monitored by your physician. I also further note, I am not a licensed medical/mental facilitator. If you under a physicians care or guidance, a written statement from that care-giver must be provided stating acknowledgment of my involvement in working with you, through hypnosis, and this statement will be retained in your file, along with contact information for that provider. Falsifying such information of failure to provide the proper forms may result in refusal of any and all sessions, with no refund of any fees paid. Additionally, if you are receiving any audio recording, you agree to not listen to that unless you are in a safe place, and not in a vehicle or while operating machinery of any kind.Session Re-Scheduling Policy *I agree to the required notice to rescheduleIt is important to keep your appointments and to arrive on time; regardless of if your appointment is via online, phone, or in-office. While I understand that things do happen at times, However, I do require a MINIMUM OF 4 HOURS NOTICE if you need to reschedule. When this notice is not given - you will forfeit that session or will be charged the full session price. This policy is strictly enforced and this is the only notification you will receive of such. Thank you. E.Wells, CPHi, CMCL @ 1st Choice Hypnosis 937-315-2730 (text or call) eva@1stchoicehypnosis.com // Misty Sue Ulm, CPH @ 1st Choice Hypnosis 937-489-4107 (text or call) sue@1stchoicehypnosis.com Your written/typed name above, and/or this electronic signature below signifies that you agree to abide by all above terms. *Submit