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Patient Forms

Have you ever been hypnotized
MEDICAL HISTORY Have you been under a Dr.'s care in the past year?
Have you ever been treated for an emotional problem?
If yes, are you currently receiving treatment or counseling?
Have you had any prolonged illness?
Have you ever been treated for
Any previous efforts to solve the problem?
Are you currently undergoing medical or psychological treatment for the above problem?
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Thank you! Your information has been submitted successfully. We will contact you within 1 business day. Elite Hypnotherapy

If you wear HARD contact lenses, before your session, please remove them, as they inhibit your ability to relax.

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