Emotional Detox – Hypnosis Session Please complete the form below.Should you have any of the contraindications, please contact me for a refund. Please enable JavaScript in your browser to complete this form. - Step 1 of 2Name *FirstLastEmail *Telephone NumberBirth DateHow old are you?Emergency Contact NameEmergency Contact NumberHow did you Find Me?Google SearchFacebookTwitterInstagramTiktokOtherAre You Currently using any medication?YesNoI 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 ContraindicationsYes I have ContraindicationsWhich of the above contraindication's have you been diagnosed with?Are you using any recreational drugs? YesNoDo you have any physical/medical Condition? YesNoIf yes to the above question, are you consulting with your GP on this matter?YesNoHave you experienced hypnosis or hypnotherapy sessions?SelectYesNoHow many?For what purpose?What was the outcome?Do you have any questions about what hypnosis is?NextI 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. YesI am participating in hypnosis by my own choice because I want to be here.YesI 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.YesI understand that my progress involves how I care for myself physically, mentally, emotionally, and spiritually.YesI 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.YesI 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. YesI 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. YesI 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.YesI 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.YesI understand that our session will be digitally recorded for my later use and that and Neels (CD) Viljoen retains the copyright of these recordings. I also understand that in these types of metaphysical sessions, the energy in the room can affect the equipment and recording resulting in static or blank recordings.YesI understand that often in Hypnosis sessions, universal information is provided through the client to benefit all of humanity. I agree to allow Neels (CD) Viljoen to share this information and any accompanying story either on video or in written form in blogs or books if my first and/or last name and personal and relevant details are omitted and/or changed. (On YouTube videos, you will agree on what to omit.) YesNoI 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.YesI 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 agreeAll sales are final, and no refunds will be given.YesSubmit