Emotional Detox Hypnosis Session Questionare | Wellness Centre in Moreleta Park, Pretoria

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Past Life Regression | Reiki | Soul Talk | Emotional Detox | Bookings

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Emotional Detox Hypnosis Session Questionare

Emotional Detox Hypnosis Session

Please complete the below form:

- Step 1 of 2

Name *

First

Last

Email *

Telephone Number

Birth Date

How old are you?

Emergency Contact Name

Emergency Contact Number

How did you Find Me?

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Other

Are You Currently using any medication?

Yes
No

I confirm that I have not been diagnosed with any of the following contraindications: Schizophrenia; Pathological personalities; Alcohol or drug psychosis ;Senility; Epilepsy; and narcolepsy are conditions usually regarded as contraindicated. Bi-polar conditions and clinical depressive illnesses or those exhibiting suicidal tendencies. Serious heart conditions may also be contraindicated.

No Contraindications
Yes I have Contraindications

Which of the above contraindication's have you been diagnosed with?

Are you using any recreational drugs?

Yes
No

Do you have any physical/medical Condition?

Yes
No

If yes to the above question, are you consulting with your GP on this matter?

Yes
No

Have you experienced hypnosis or hypnotherapy sessions?

How many?

For what purpose?

What was the outcome?

Do you have any questions about what hypnosis is?

I fully understand that Neels (CD) Viljoen is not a doctor nor has a degree in Psychiatry and can neither diagnose nor treat any type of physical or mental disorder.

Yes

I am participating in hypnosis by my own choice because I want to be here.

Yes

I understand that any suggestion that is made during the hypnosis session is only part of a personal and educational motivation program and is only informative.

Yes

I understand that my progress involves how I care for myself physically, mentally, emotionally, and spiritually.

Yes

I understand that the hypnosis session is exclusively for educational and emotional reasons. It is not intended to be in any way, used as medical or psychological advice. This can only be given by a medical professional or a mental specialist.

Yes

I understand that transformation is a process and that it can take time.

Yes

I am willing to be guided through relaxation, visual imagery, hypnosis, and/or stress reduction techniques. I am aware that these modalities are spiritual-based and non-medical in nature, and it is my responsibility to consult my regular doctor about any changes in my condition or changes in my medication.

Yes

I understand the above modalities are not substitutes for regular medical care and I have been advised to consult my regular medical doctor or health-care practitioner for treatment of any old, new, or existing medical conditions.

Yes

I understand that being hypnotized is not being asleep. During a deep hypnotic trance, you can open your eyes, speak, laugh, walk and you may be aware of everything that happens around you. You can even open your eyes and think it is not working and are not hypnotized. But when you allow those feelings or thoughts that come to your mind to flow freely as Neels Viljoen speaks to you, you will relax and remember forgotten events in this life or a past life.

Yes

I understand that change is my own and complete responsibility. I understand all healing is self-healing and that Neels Viljoen is only a facilitator in the process of helping me to solve my own problem(s). It is my responsibility to be open and honest, provide accurate feedback and be forthcoming with details and information that may help me achieve my outcomes.

Yes

I understand that if I make travel arrangements to see Neels Viljoen, I will not hold Neels Viljoen responsible for any costs incurred, such as travel or hotel, if the session is cancelled. We strongly suggest you protect yourself with Travel Insurance. In the event of a disaster (natural or man-made), emergency, accident or illness, sessions can be cancelled on short notice. Neels Viljoen will not conduct a session if he is ill.

Yes

I am of legal age and understand that I am entering a cooperative relationship of my own free will. I accept that I am a willing participant in this cooperative relationship that will employ hypnotic techniques, regression, and any other appropriate modality by Neels (CD) Viljoen. Therefore, I do hereby release and discharge Neels (CD) Viljoen from all claims of damages, copyright, demands or actions whatsoever in any manner arising from or growing out of my cooperative participation. Any concerns or questions can be addressed by the International Association of Interpersonal Hypnotherapy as the governing and credentialing body. I have received and read this Client Information and Agreement Form and understand what I have read.

I agree

All sales are final, and no refunds will be given.

Yes

Please leave this field empty

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