Athlete's Paperwork "*" indicates required fields Step 1 of 3 33% Athlete Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Email* Referred By: Google Search Yelp Facebook Doctor/Therapist Referral Family Member/Friend Wise Mind Hypnosis Website Other Birth Date* Month Day Year Age*Sport(s):*Name of Your School or Club Team:*Have you ever had a sports injury or experience that affects your mindset? If so please describe.Is there anything else you think will be helpful that I should know about you?Consent* I agree to the terms and policies.I understand that good and lasting results may require several hypnosis sessions and that I will be required to practice self-hypnosis and visualization. I am responsible for actively cooperating with, and participating in my program. Jordan Bloom, CPH shall not be held accountable for the results I attain. I understand that like other healing arts, the practice of hypnosis and hypnotism is not an exact science. Therefore, results are not guaranteed, nor are refunds given for services rendered. Sessions at Wise Mind Hypnosis are videotaped, held confidentially and become the property of Wise Mind Hypnosis. I understand all information about me will be kept strictly confidential. Athlete Signature / Parent Signature*Date Month Day Year Mental Edge Hypnosis- ReleaseI realize all hypnosis is self-hypnosis, and I hereby allow Jordan Bloom to use and teach me self-hypnosis. I realize there are no guarantees, and I in no way hold Jordan Bloom or Wise Mind Hypnosis liable. I am willing to be hypnotized of my own free will and take full responsibility. I am signing this before being hypnotized.I realize Wise Mind Hypnosis workshops, courses, lectures and sessions offer an opportunity to recognize and experience my own personal journey. Any direction given through teaching or personal interaction with me should be followed only if I choose to do so of my own free will. Jordan Bloom acknowledges and honors each person's right to discern if they wish to adopt within their belief system, or not, the programs offered.Investment Structure: Basic Investment Package Rate ($750 for 4 sessions.) The first session is 90 minutes and subsequent sessions are 60 minutes. Payment plans available. (Subsequent sessions at the client's discretion are $175.) As with other healing arts, the practice of hypnosis and hypnotism is not an exact science. Therefore, results are not guaranteed, nor are refunds given for services rendered. You may pay for services by check, cash, Venmo or credit card. By signing below, I understand the above statement. Therefore, this program or session does not take the place of any medical and/or psychological health care. I will direct these issues to the appropriate medical/psychological health care provider. Appointment Success Agreement* I agree to the rescheduling policy and agree to pay for missed appointments.Life happens! If for some unforeseen reason you cannot keep a scheduled appointment, you agree to provide 48-hour notice (2 business days) to reschedule. If advanced notice is not given, that appointment will be considered a paid session. If you are paying by the session, your credit card on file will be charged for the missed appointment. Athlete/Client Signature* Parental/Legal Guardian Treatment Consent - Complete Only if Athlete is Under Age 18I am the parent/legal guardian of Whose birthdate is Month Day Year Consent I consent the aforementioned minor child receives hypnosis from Jordan Bloom, Certified Professional Hypnotist at Mental Edge Hypnosis.Parent's Printed Name Parent Signature (If athlete is under 18)Date Month Day Year 72332