Athlete’s Paperwork - Jordan Bloom Mental Performance Training

Step 1 of 3

Athlete Name*

First Last

Address*

Street Address City State ZIP Code

Cell Phone*

Referred By:

Google Search

Yelp

Facebook

Doctor/Therapist Referral

Family Member/Friend

Wise Mind Hypnosis Website

Other

Birth Date*

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?

Athlete Signature / Parent Signature*

Date

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 ($1550 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.

Complete Your Intake Form

Mental Edge Hypnosis- Release

Parental/Legal Guardian Treatment Consent - Complete Only if Athlete is Under Age 18