Intake Form

Stacie Ford, Certified Professional Hypnotist

stacie@elevateyourmindhypnosis.com

Emergency Contact Information


Hypnosis techniques are not in any way meant as a substitute for standard medical, psychiatric, or psychological treatment. Any changes to your current treatment should always be monitored by your physician. I also further-note, I am not a licensed medical or mental facilitator and should not be seen as being such. If you are under a physician's care or guidance, a written statement from that provider acknowledging my involvement with you, thru hypnosis, will need to be given and kept in your file, along with contact methods of that provider, in case of an emergency. Falsifying such information or failure to provide the proper forms will result in refusal of any and all sessions. Additionally, if you are receiving an audio recording, do not listen to that in a vehicle, or while operating machinery or power tools of any kind.

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Investment: $37.00