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Intake for Hypnotherapy Services

Before you begin, please download and read our Terms of Service in Step 2 above.

Please allow yourself 15-20 minutes to complete your Intake. 

   Click the button below to start your Intake.

Start

Question 1 of 25

Before we get started, why are you completing this Intake?

A

I'm getting ready for my Free Initial Consultation.

B

I'm getting ready for my first paid Hypnotherapy / EFT session.

C

I'm doing the Intake for someone else.

Question 2 of 25

Let's Establish Your Legal Authority to Complete this Intake.    

- Are you the New Client, or are you completing this Intake for someone else? 

- If the New Client is someone else, what is your legal role for them? 

 

• For a minor child or adult ward, we must have a separate Parental or Custodial Consent before the first appointment. We'll send you the form and discuss the details with you later. 

 

• If you're completing this Intake for someone else who is a legally competent adult, please stop here.  Legally competent adults, unless physically unable, are responsible for completing their own 5 Easy Steps to Get Ready.  Thank you! 

A

I am the New Client and I'm a legally competent adult according the laws of my state.

B

I am the minor child's custodial parent and I have legal authority to give consent.

C

I am the minor child's non-custodial parent and/or I do not have legal authority to give consent. However, I will furnish contact information for you to send the Parental Consent form for the custodial parent or legal guardian to sign.

D

I am the minor child's (or adult ward's) legal guardian.

E

I'm helping a legally competent adult who is physically unable to complete the 5 Easy Steps by their own request and with their explicit permission.

F

I was completing this Intake for another legally competent adult, and I will ask that person to do their own 5 Easy Steps to Get Ready.

Question 3 of 25

Parent or Legal Guardian:  If you're the adult with legal authority to complete this Intake and give consent for a minor child or adult ward, what is your full name?

(Please use the format:  First Middle Last

If this question does not apply to you, please put "Does not apply".

Question 4 of 25

Contact Information for Parent or Legal Guardian:  If you're the adult with legal authority to complete this Intake and give consent for a minor child or adult ward, please enter your contact information: 

• Phone number(s) - In the United States please use this format:  xxx-xxx-xxxx. If you're outside the United States, please include your country code.)

• Email address

• Mailing address - Please put your address in the format that would be used to send you a letter or package, including postal code and country, if necessary. 

 

If this question does not apply to you, please put "Does not apply".

New Client Information

The following questions refer to the New Client, that is, the person receiving the appointment. 

If you are the New Client, please go on to the next question.

However, if you are not the New Client, please note: 

New Clients must complete their own 5 Easy Steps to Get Ready.

There are three exceptions:

1. A minor child for whom you are the custodial parent or legal guardian;

2. An adult ward for whom you have legal authority to give consent; or

3. A legally competent adult who is physically unable to complete this Intake and gives you explicit permission to assist them. 

If the New Client is someone other than you (and you have legal authority or permission), please answer the questions that follow as if you were the New Client. 

Question 6 of 25

What's your full name?  (Please use this format: First Middle Last)

Question 7 of 25

What's Your Date of Birth?  Please use this format:  MM/DD/YYYY

Question 8 of 25

What pronouns should we use for you?  

We respect all people, regardless of race, age, religion, economic class, sexual orientation or gender. 

(Select all that apply)
A

She / her

B

He / him

C

They / their

D

Another pronoun combination not listed here.

E

I prefer not to say.

Question 9 of 25

What telephone numbers should we use to reach you? 

• Put your best or preferred number first and any others in order of preference.

• Include the area code (xxx-xxx-xxxx in the US) or country code.  

• Note what type of number it is:  Mobile, Landline, Home, Work, a Friend's, or other information that will help us contact you.

• If you have an Apple device and want to use FaceTime, please let us know that too. 

Question 10 of 25

What email address should we use for you?  If the email belongs to someone else, please let us know. 

Question 11 of 25

What is your mailing address for physical mail?  Please enter your address as you would use it to send a letter or package to yourself, including apartment, box number, city, state or province, country and zip or postal code.

Question 12 of 25

What is your present occupation?  If you're not currently engaged in that occupation, what is your usual occupation?  What do you usually do with most of your time? 

Question 13 of 25

What is the highest level of education that you've completed so far?  (No judgment here. Education does not necessarily equal intelligence or ability! We just ask to understand your situation better.) 

A

Grade School (Primary/Elementary)

B

High (Secondary) School

C

Trade or Technical School

D

Some college

E

Associate's Degree

F

Bachelors Degree

G

Some Graduate Studies

H

Graduate Degree

Question 14 of 25

Who's most important in your life?  This might be your spouse, romantic partner, family member, friend or someone else you may refer to in your sessions. Please state your relationship with them. 

 

We will not share information with them about you without a signed Release of Information from you. We'll get you the form upon your request. 

 

We'll ask about who you want to list as your emergency contact next.  

Question 15 of 25

Who should we contact in case of an emergency? Please provide us with their full name, their relationship to you, their best phone number and their email address. This person can be someone different from the person (or people) you listed above.

 

We will not contact this person except in case of emergency, or unless you specifically ask us to do so. 

Question 16 of 25

Have you ever been hypnotized or used Emotional Freedom Technique (EFT or Tapping) before?

(Select all that apply)
A

I've never been hypnotized before.

B

I've never used EFT before.

C

I don't think I can be hypnotized.

D

I'm not sure what will work for me.

E

I've been hypnotized before and it helped me.

F

I've been hypnotized before but it didn't last or didn't work as well as I would have liked.

G

I've used EFT before and it helped me.

H

I've used EFT before but it didn't seem to work or last.

I

I've used something similar to EFT, like EMDR or another energetic modality, before and it did help me.

J

I've used something similar to EFT, like EMDR or another energetic modality, before and it didn't help enough.

Question 17 of 25

What are your specific goals for your Hypnotherapy / EFT sessions?  In your own words, what are you hoping to accomplish or create for yourself? 

Question 18 of 25

Below are some of the specialities we offer in Hypnosis/ Hypnotherapy/ EFT. 

Which ones interest you? 

(Select all that apply)
A

Reducing Your Anxiety and Panic (See also our Mastering Relaxation course)

B

Improving Your Relationships (See also our signature online course, Relationships for Conscious Living)

C

Lose Weight and Happily Maintain It (AHA Certified Specialist)

D

Stop Smoking Program (AHA Certified Specialist)

E

Advanced Emotional Freedom Technique (EFT or Tapping) (AHA Certified Specialist)

F

Hypnosis and EFT for Pain Management (AHA Certified Specialist)

G

Opioid Withdrawal Program (Signature Program)

H

Mobility After a Stroke (Signature Program)

I

ADD/ADHD (Any Age - Children or Adults) (AHA Certified Specialist)

J

Pre- and/or Post Surgery Hypnosis for Better Outcomes (AHA Certified Specialist)

K

Immune Disorders (including diabetes, cancer and more) (AHA Certified Specialist)

L

Post-Traumatic Stress Disorder (PTSD) (AHA Certified Specialist)

M

Sports and Peak Performance in Any Field (AHA Certified Specialist)

N

Academic / Career Success (Signature Program)

O

Joyful Childbirth and Pregnancy (AHA Certified Specialist)

P

Past Life Regression & Future Life Progression (AHA Certified Specialist)

Q

Other - Something not listed here

Question 19 of 25

The Scope of Hypnotherapy Practice 

 

(a) The general scope of Hypnotherapy practice includes vocational and avocational goals and self-improvement

 

(b) Issues and goals that involve a mental health or medical health nature, component or origin are treated in Hypnotherapy through licensed mental health or medical referrals only, in accordance with the Hypnotherapists' Code of Ethics.

 

(c) Furthermore, there are no guarantees as to the results or progress to be made, only that the Hypnotherapist will, to the best of their ability, endeavor to accomplish the objective(s) of my sessions.

 

For more information, please see section "I. Disclosure of Services" in our Terms of Service.

A

I understand and agree with the above statements. I also understand that, if one or more of my goals involves medical or mental health, in the sole determination of the Hypnotherapist, that I may be required to get a Healthcare Referral from a licensed provider.

B

I do not understand/agree with the above statements, and I withdraw my request for Hypnotherapy / EFT.

Question 20 of 25

Some goals and issues require a Healthcare Referral from a Licensed Provider.  

Do any of the following apply to you?

• One or more of your goals relates to a medical, dental or mental health issue. 

• You're a female and want to lose 25 pounds or more overall. 

• You're a male and want to lose 35 pounds or more overall. 

• You're not sure if your goal will require a Healthcare Referral. 

 

If any of the above applies to you, you may need a Healthcare Referral.  

• Getting your referral is relatively easy. 

• After you finish this Intake, just go back to Step 2 on this page and download the Healthcare Referral PDF with everything you need. 

•  You may have your first session without a Healthcare Referral as we create a plan for achieving your goals. 

•  Please be sure to send us your Healthcare Referral from your Licensed Provider before your second session.

 

Please select your answer below to continue your Intake. 

A

I may or do need a Healthcare Referral for some goals or issues.

B

I don't think I need a Healthcare Referral for my goals or issues at this time. I understand that I may be required to get a Healthcare Referral if my Hypnotherapist says I need one to continue.

C

I'm not sure whether I need a Healthcare Referral and I'd like to talk it over with my Hypnotherapist.

Question 21 of 25

ADDITIONAL CONDITIONS 

The space below is for any additional conditions of service between you and Transformation Roadtrip LLC, including but not limited to, special arrangements or requirements to be included in this agreement.

Please follow any instructions we may have provided you for this space. 

Question 22 of 25

If you are participating in one of our Weight Loss Hypnosis Programs, please choose the Weight Loss Hypnosis Program that is best for you below. 

If you're not going to do a Weight Loss Hypnosis Program at this time, please select "E - This question doesn't apply to me."

 

Additional Terms of Service apply.  Please refer to our Terms of Service.

 

A

Private, One-on-One Weight Loss Program, Fully Customized to Me - $177 per 90-minute session, including a downloadable recording of the hypnosis portion of each week's session, customized to me, plus access to the 8-Week Online Course, "Lose Weight from Within" — $177 per Weekly Private, Remote Session ($1416 total for 8 weeks)

B

8-Week Online Course, "Lose Weight from Within," with 8 Weekly Personalized Coaching Calls (10-20 minutes each week) to help me keep on track and address any obstacles or challenges to my success — $427 Course Fee including Personalized Coaching Calls

C

8-Week Online Course, "Lose Weight from Within," DIY style ("do-it-yourself" or self-study) so I can do the program on my own and participate in the course Comments to ask questions and get support — $197 Stand-alone Course Fee

D

I don't know which program to choose and would like to talk about my options. Please contact me.

E

This question doesn't apply to me.

Question 23 of 25

DECLARATION OF CONSENT:

1. I have read and understood these Terms of Service including the Disclosure of Services and Acknowledgment of Fees and Services. I have also read Jackie Ambrow's Biography and Training. 

2. I accept the Terms of Service and and I agree to Electronic Consent in lieu of my physical signature. 

3. I agree and understand that the Terms of Service may be updated from time to time and that my continued participation indicates that I accept any update. 

4. I agree and affirm that I am competent and of legal age to enter into this agreement. I agree that any legal dispute arising out of this agreement will be resolved according to the laws of the State of Texas.

5. I agree and affirm that I will do my best to resolve any dispute with integrity on my part and in a direct, friendly, respectful, honest and prompt manner, and I understand that you will do the same! 

A

Yes, I hereby give my electronic consent and agree to the Terms of Service.

B

No, I do not agree with the Terms of Service or the Declaration of Consent. I understand that I will not be accepted as a client and will NOT receive a Free Initial Consultation

Question 24 of 25

Please type your full name as your signature for your Electronic Consent. 

Question 25 of 25

Please enter today's date for signing your Electronic Consent. 

Please use the date format MM/DD/YYYY. 

Confirm and Submit