Pediatric Intake Form

Name (Required)

Parents' names

Childs Birth Date

Sex Sex Female Male

Email Address (Required)

Address

City

Postal Code

Number of children in household

Ages of children

Any serious medical conditions Past or Present?

Epilepsy or asthma?

List any current health problems

Reason for requesting hypnosis session

How did you hear about my service?

Please list any other conditions occurring in your life that you believe are negatively affecting you in any way.

I Agree I Agree By submitting this form I hereby authorize Raymond Elias to use hypnosis with my child for the purposes outlined in this form and for future purposes that may be mutually agreed upon. I understand that the success of the hypnosis session depends greatly on my child's ability to relax and desire to create change. I understand that because the results of my sessions depend greatly on my child's participation that Raymond Elias cannot offer any guarantee of the success of the hypnosis session. I am aware however that Raymond Elias will do everything reasonably in his power to ensure my child's success.

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