Healthy Visions

Please complete this form (All information is strickly confidential)

Your Information

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Name: *
Email: *
Gender: *
Male Female
Address: * * * *
Work Phone:
Home / Cell Phone: *

Age: *
Height: *
Weight: *
Marital Status:
Spouse's Name:
Your Occupation: *
Children's Names:

Diagnosis/Complaint/Purpose for visit: *
What you do for hobby or relaxation: *
Have you ever been treated for emotional problems? *
If yes, please explain:
Have you been treated for:


Virual analog scale: 1 is very good and 10 is very bad.
Discomfort / Pain: Tody(required)
Week Avg: *
Sleeping Habits: Tody *
Week Avg: *
Quality of life: Today *
Week Avg: *
Have you experienced Guided Imagery, Meditation, Yoga, or Hypnosis? *

Medications: *
Do you have any allergies or phobias? *
How did you hear of us? *

* X * I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, and stress reduction processes and techniques for the purpose of vocational or avocational self-improvement. I understand that the hypnosis I am receiving is not a substitute for normal medical care and I have been advised to discuss this hypnosis with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my medical doctor for treatment of any new or old illnesses. Services are non-transferable. 4 Session Package must be completed within 120 days as recommended. Sessions may be video taped for your protection and for our protection. Mark Discomfort / Pain Areas

Signature: *
Date Signed *
Name I Like to be called:

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