Pediatric Intake Form

Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Referred By
Parent/Guardian Name
Parent/Guardian Email
Home Phone
Parent/Guardian Cell Phone
Client Cell Phone
Client Email
Home Address
City
St
Zip
Parent/Guardian Occupation
Employer
Other children and family members living in the home (names and ages)
Other children and family members living out of the home (names, ages, where they live)
Does the client have any medical conditions, pain, or physical discomfort (explain)
Is client suffering from anxiety, high stress, depression or other mental disorder (explain)
Has client experienced hypnosis before? Yes No. Under what conditions? (explain)
What issues, behaviors or conditions are you seeking help with
Favorite hobbies or things to do
CONTRACT AND CONSENT FOR HYPNOTHERAPY, DISCUSSION, AND ACTIVE LISTENING.
Billing: Fees are expected at the time of service. Cash, check, Visa, MasterCard, American Express, and Discover are accepted. If you are having difficulty paying, please ask about the financial assistance program. Also, please remember your appointment is reserved specially for you. If you cancel an appointment without 48 hours' notice, it is very difficult to reschedule someone else for that time. If you cancel or miss an appointment without at least 24 hours' notice, your credit card will be charged the full regular amount.
Medical Treatment: Under IDAHO law a Hypnotherapist may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. Hypnosis is not a cure for anxiety, depression, or any other mental health or medical condition. Many medical conditions are improved from reducing stress and/or symptoms, such and pain, with hypnotherapy when conducted in conjunction with medical and/or clinical treatment. Some medial conditions require a referral from a physician. River Valley Hypnotherapy works closely with many counselors, physicians and nurse practitioners throughout the Treasure Valley and can offer referrals for licensed clinical professionals.
Client Rights: Clients and their parents/guardians are encouraged to address concerns during therapy and may assert any of these rights without retaliation. You have the right:
- To transfer services to another practitioner if you desire a medical diagnosis or other treatment.
- To refuse hypnosis services or to terminate services at any time.
- To be free of physical, verbal or sexual abuse.
- To have your needs addressed in a competent and professional manner.
- To ask questions about procedures, theoretical orientation and personal biases of the therapist.
- To have access to my written record about the client.
Confidentiality: I will not release any information to anyone without a written authorization from the parent/guardian, except as provided for by law as stated below.
Ethical Responsibilities: The Hypnotherapist is responsible to protect the client’s rights and to protect the public from harm. In rare cases, where these responsibilities conflict, the Hypnotherapist is legally bound to "break" confidentiality to protect either the client or third parties from harm. Suspected or reported child abuse requires reporting to the Idaho Child Protective Service. If the client should become dangerous to an identifiable third party, the Hypnotherapist must notify the third party and local law enforcement. If the client threatens to harm him or herself in a clear manner, steps will be taken to preserve his/her life, including voluntary hospitalization, notification of law enforcement and commitment procedures.
Client and Parent/Guardian Agreement: Your signature below indicates you understand hypnosis represents a potentially powerful tool, but that results vary from person to person, that there is no expressed or implied guarantee of results, that the results you receive are directly related to the client’s attitude, desire for change, and willingness to follow the reasonable and responsible directives of the Hypnotherapist. In addition, you agree and understand that the Hypnotherapist is ethically bound to decline the rendering of services to your child, if it is shown that your child does not or no longer benefits from such services or in the event the Hypnotherapist no longer has a good faith/belief that the client is a good candidate for services. I hereby consent for my child to receive hypnotherapy, discussion, and active listening services from Jessica Hixson. I release Jessica Hixson, from any liability and waive any and future claims that I may have or that may be made on my behalf arising out of the assistance given my child by Jessica Hixson. I have read this document and understand what I have read and agree to its terms.
Client Name (print)
Parent/Guardian Name (print)
Signature
Date
Date Format: MM slash DD slash YYYY