Your subconscious mind, the part of the mind you’re going to access during hypnosis, is the
goal or action oriented part of your mind. As a result, it’s best to get clear about your goals or
intentions prior to starting your hypnotic process.
Please put your measurable goal(s), in priority order, below. E.g. As a result of our work
together I intend to permanently release 20 pounds of excess weight within 10 weeks.
As a result of my hypnosis session(s) I intend to:
Once you have your goals outlined it’s recommended that you spend a few minutes per day,
prior to your sessions, visualizing yourself having achieved your goals and experiencing all the
benefits of your success.
Two – Way Release of Confidential Information
to release to each other any and/or all medical, psychological or educational information they may have pertaining to me.
This authorization for the release of confidential information expires ninety (90) days from the date above. I understand that I may revoke this release at any time on written notice to the parties involved, and the information released prior to the receipt of such notice is not a breach of my right to confidentiality.
One – Way Release of Confidential Information
the following specific medical, psychological or educational information he or she may have pertaining to me
I state that I have examined the records to be released and approve of this release to the party indicated above. This authorization for the release of confidential information expires ninety (90) days from the date above. I understand that I may revoke this release at any time on
written notice to the parties involved, and that information released prior to the receipt of such notice is not a breach of my right to confidentiality.
I understand that by authorizing the release of my records to a third party in this way I lose any right to confidentiality or privilege over my records. I understand that by authorizing the release of my records to a third party in this way I create a circumstance where my hypnotist might be required to enter testimony in a court of law regarding me. I understand that by authorizing the release of my records to a third party in this way I create a circumstance where they may reveal the information contained in my records to whomever they wish. I understand that by authorizing the release of my records to a third party in this way I create a circumstance where the records released may be subpoenaed by interested parties to use as evidence in a court of law.
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Smoking Cessation Homework
Congratulations on your decision to become a non-smoker. Please complete the following
homework as soon as possible so that you’ll begin your process of quitting even before you
come in for you session.
- Consider switching to a “natural brand” of cigarettes to ease any withdrawal sympotoms and begin to disconnect from your brand.
- On a piece of paper that will fit into the sleeve of your pack make a list of all the things that you HATE about smoking. E.g. yellow teeth, bad breath, smell, cost, cough, low energy etc. Put it in the sleeve of your pack and read it before you light up.
- Make another list of all the benefits that you’ll receive as a non-smoker and put that list on the other side of your pack and read it when you’re done smoking.
- When you’re smoking – just smoke. It’s only a few minutes of your time and it is important for you to become conscious of exactly how cigarettes smell, taste and feel.
So no driving, no talking on the phone, no working on the computer – just smoking. And, don’t hold your cigarette – put the cigarette down between puffs.
- Get a calculator and figure out how much money you’ve spent on cigarettes and cigarette related illness since you started smoking. Then figure out how much time you’ve spent since you stared smoking. Then make a list of 3 things you would have rather spent that money and time on.
- Have your last cigarette a half hour prior to your session and announce to yourself and to that cigarette that it is your last. E.g. “This is my last cigarette. I am now a
nonsmoker and will be a nonsmoker for the rest of my life. Cigarettes you are no longer in control of me. I’m in control of me – my thoughts, my actions, my health and my
money. I am a NON SMOKER!!!!”
- Bring your homework and any remaining cigarettes or lighters with you when you come. You will be
a non-smoker when you leave the Center. Congratulations!!
Weight/Food Input Form
E.g. Were you deprived of or controlled with food as a
child? Were you rewarded with food? Were you a member of the clean plate club?
E.g. I’m afraid of getting extra
E.g. “I want to release weight but….
Weight Release Growth Work:
Step 1: Simply become aware of what you’re eating. The best way to become aware is to accurately write down whatever it is that you’re eating throughout the day so we’ll be starting your process with accurate information. Or better yet, load the Cronometer App into your phone and log what you’re planning on eating for each meal prior to eating.
Step 2: Become aware of why you’re eating. Physiological hunger, boredom, stress, other emotions and make a note of the reason next to the food so we can become aware of any patterns of emotional eating.
Step 3: Please weigh yourself before your first session, again so we’re working with accurate information. If you’d like to take measurements of your waist, hips, upper arms and thighs you’re welcome to.
Step 4: If you’re not doing any exercise currently make a commitment to do something – anything that equals moving your body for 10 minutes per day before your session. E.g. walking, dancing, yard work, biking, stretching, playing with your children, etc.
Step 5: Get a refillable water bottle that you like – ideally one that’s at least 32oz – glass or metal. And if you feel that walking is going to be your primary form of exercise it’s worth investing in a simple pedometer.
Step 6: Bring your homework with you when you come. See, you’ve already taken six steps down your path to lean, fit and healthy. We look forward to working with you. See? You have already taken six steps down your path to lean, fit, and healthy.
We look forward to working with you.
Mind Matters Hypnosis
Dear Health Care Provider
requesting instruction in self-hypnosis.
It is our policy to be sure that the attending physician or other health care providers are aware that their patient is practicing hypnotism and will, as research supports, experience several positive shifts in their overall health as a result.
Consulting Hypnotism is motivational coaching by means of hypnotism and is not considered health care. Therefore, health insurance does not normally cover hypnotism and your patient will be paying us directly for our services.
If you have any objection to your patient receiving hypnotism please inform us immediately at (860) 693-6448 or firstname.lastname@example.org. If there is anything in specific you would like us to include in our work with your patient, such as pain control, appetite management, blood pressure or diabetes management, stress reduction, smoking cessation, anger management etc. please let us know.
We are Consulting Hypnotists in good standing with the National Guild of Hypnotists and our continuing education is current. We practice in accordance with the Code of Ethics, Standards of Practice and Recommended Terminology of the National Guild of Hypnotists, and give every client a comprehensive Client Bill of Rights which fully discloses our training and practice limits.
Please feel free to learn more about our services and longstanding service to the community, on our website at www.mindmattershypnosis.com. We would also be happy to discuss our services with you and/or your staff at your convenience.
The Mind Matters Hypnosis Team
Avon, Glastonbury & Guilford, CT
Parent Approval Form
and my child are confidential and will not be shared with me without the expressed permission of my child.
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