Athlete's Paperwork
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Athlete Name
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First
Last
Address
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Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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- Release
I 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 Mental Edge 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 ($1450 for 4 sessions.) 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.
Parental/Legal Guardian Treatment Consent - Complete Only if Athlete is Under Age 18
I 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
Date
Month
Day
Year