Katherine Zimmerman ~ Confidential Client Information
Appointment date
Phone number for counselor/physician
Emergency contact
Check at least one and/or fill in the box below.
I have read and received a copy of the State required disclosure
I agree to pay $75 for any missed appointments, late cancellations or late changes. 24 hour notice required
Hypnosis is a combination of concentration and mental relaxation very similar to meditation. The best hypnotic subjects are creative, intelligent and curious. Motivation, the ability to concentrate, to use your imagination, and to think positively also help you to be successful. I understand that hypnotherapy is not a substitute for medical or psychiatric treatment. I agree to cooperate in this process and to complete any homework assigned. I have read the above statements and understand the probability of my benefiting from hypnosis. I have been advised that I am free to terminate any or all sessions at any time. I am submitting my signature electronically.