Consent Form

    PERSONAL INFORMATION

    1. Date:

    2. Name*:

    3. Address:

    4. E-mail*:

    5. Mobile Phone*:

    6. Home Phone*:

    7. Occupation:

    8. Employer:

    9. Date of Birth*:

    10. NRIC No*.:

    11. Marital Status: SingleMarriedDivorcedWidowed

    12. Previous Medical / Psychiatric History:

    13. Presenting Symptom(s):

    14. Goal of Therapy:

    IN CASE OF EMERGENCY

    1. Name*:

    2. Contact Number*:

    3. Relationship To Client*:

    CONSENT TO THERAPY

    I do hereby seek and consent to take part in the treatment by the therapist at Mind Your Health. I understand that developing a treatment plan with the therapist and regularly reviewing our work towards meeting the treatment goals are in my best interest. I agree to play active role in this process.

    I give my consent for the therapist to contact physician(s) if necessary for information related to my clinical conditions.

    I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of the appointment. If I do not cancel and do not show up, I may be charged for that appointment in total.

    By proceeding, I understand and agree to all of the statements above.

    I founded Mind Your Health with the goal of helping people with poor mental health enhance their lives with hypnotherapy. Hypnotherapy is completely safe. You are awake and you will be in control throughout the session. I provide several types of sessions, including hypnotherapy services for anxiety, depression, sleep, weight loss, smoking, and more. So if you have depression symptoms, anxiety symptoms, stress symptoms, or anger issues, you can try my hypnotherapy treatment.