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Intake for Hypnotherapy Services

IMPORTANT: Before you begin, please download and read our Terms of Service in Step 2: Get Your Files. Please allow 15-20 minutes to complete your Online Intake Assessment. There are 24 questions. At the very end, you'll enter your name and email as your Electronic Signature. Thank you in advance for your time! 

   Click on "Start" to begin.

Start

Question 1 of 24

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

A

I'm getting ready for my Free Initial Hypnotherapy Consultation.

B

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

C

I'm completing this Online Intake Assessment for someone else.

Question 2 of 24

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 Online Intake Assessment.  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 Started.

Question 3 of 24

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" or "N/A".

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 Intake Assessment here.

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 5 of 24

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

Question 6 of 24

What's your date of birth?  Please use this format:  MM/DD/YYYY

Question 7 of 24

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 8 of 24

What telephone number(s) should we use to reach you? 

• Please include your area code (and country code if outside the United States)

• Please label your number(s) as Mobile, Landline, Home, Work, a Friend's. 

Question 9 of 24

If you are not the client (because you're a parent or guardian and completing this Intake for someone else), what email address should we use for the client? You will enter your own email address at the very end of this Intake as the person giving Electronic Consent. 

Question 10 of 24

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 11 of 24

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 12 of 24

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 13 of 24

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 14 of 24

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 15 of 24

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 16 of 24

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

Question 17 of 24

Below is a list of hypnotherapy specialties we offer. Please select all that interest you.

 

* The American Hypnosis Association has certified Jackie Ambrow, MA, CHt in the Hypnosis/EFT Specialities marked with an asterisk (*). 

 

** Two asterisks denote Jackie's Signature Hypnotherapy Programs. 

 

(Select all that apply)
A

Healthier, Happier Relationships (All Kinds) **

B

Hypnosis for Anxieties and Fears *

C

Hypnosis for Clients with Cancer *

D

Hypnosis for Attention Deficit Disorders (ADD/ADHD) in Children and Adults *

E

Hypnosis for Joyful Pregnancy and Childbirth *

F

Hypnosis for Immune Disorders (plus Diabetes and Cancer) *

G

Hypnosis for Improved Mobility after a Stroke ** Read the Harvard Robotics Program's study: http://www.biorobotics.harvard.edu/pubs/sdthesis.pdf

H

Hypnosis for Pain Management *

I

Hypnosis for Tinnitus *

J

Past Life Regression * and Future Life Progression

K

Hypnosis for Post-Traumatic Stress Disorder (PTSD) *

L

Pre- and Post Surgery Hypnosis * for fewer complications, less pain and faster recovery

M

Reduce Stress and Master Relaxation **

N

Self-Love and Emotional Self-Care **

O

Stop Smoking Hypnosis * (Stop Chewing and Stop Vaping)

P

Sports Hypnosis and Peak Performance * (applies to all kinds of performance)

Q

Tapping for Better Health and Self-Improvement - Advanced Emotional Freedom Technique *

R

Opioid Withdrawal Protocol ** (a 4-pronged approach to getting off opioids)

S

Weight Loss Hypnosis *

Question 18 of 24

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 in order to continue receiving Hypnotherapy services.

B

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

Question 19 of 24

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 Instructions and Form (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 20 of 24

Are you a military veteran or active duty military now? 

Veterans and active duty military personnel qualify for a 10% discount off public pricing for Private Hypnotherapy Sessions. Proof of service may be required.

A

Yes, I'm a military veteran.

B

Yes, I'm on active duty in the military.

C

No, I'm not a veteran or active duty military.

Question 21 of 24

Silver Membership in Positively H.U.B. Has Its Perks

You can maximize your savings, get access to two weekly group sessions to help you create your next breakthrough, and qualify for discounts plus needs-based a "sliding scale" if you need it for our Hypnotherapy Programs, all for a surprisingly low monthly subscription. Please refer to the Terms of Service for the most up-to-date information on Silver Members-only discounts and benefits. (Seriously! Go read it!)

We offer monthly membership for two reasons:

1) For you: To maximize your savings and your breakthroughs and offer you more benefits.

2) For us: To maximize our efforts to serve you and to make our services more accessible and affordable for more people. 

To explore your membership options, please visit https://positively-hub.com

A

I love perks! I'm already a paying Silver Member of Positively H.U.B. and I'm all set up to maximize my savings and my breakthroughs.

B

I want more details! I want to maximize my savings and my opportunities for breakthrough. I want to know more about becoming a Silver Member of Positively H.U.B. and will visit https://positively-hub.com/join to learn more.

C

I'm a veteran or active duty military and would like to apply my veteran/military 10% discount to my Positively H.U.B. Silver Membership to maximize my savings and benefits. Please send me my Coupon Code before I join as a Silver Member of Positively H.U.B.

D

No, thank you. I prefer to pay full price for my Hypnotherapy programs and services. I don't want to save money or maximize my benefits as a paying member at this time.

Question 22 of 24

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. 

Remember: you qualify for a discount if you are a paying Silver Member of Positively H.U.B.  Ask for your Coupon Code to use during Checkout for your Weight Loss Hypnosis Program. If you're not a Member yet and would like to join, please go here:  https://positively-hub.com/join 

 

If you are 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, Fully Customized Weight Loss Hypnotherapy Program. Private Sessions by phone or on Zoom, live hypnosis in my session each week, a downloadable recording of my hypnosis from each session, plus access to the complete 8-Week Online Course, "Lose Weight from Within" *** Bonus: After I complete my 8-week private program, I may continue with Private Hypnotherapy at the same reduced rate until I reach my weight goal! — Single Payment of $1800 for 8-Week Program, or Two Monthly Payments of $900, or $225 per weekly session

B

Personalized Coaching + 8-Week Online Course, "Lose Weight from Within.” Includes 8 Weekly Personalized Coaching Calls (10-20 minutes each week). I want to save money and get weekly coaching to help keep me on track and address any obstacles or challenges to my success. — Single Payment of $540 or Two Monthly Payments of $287

C

“DIY” 8-Week Online Course, "Lose Weight from Within". I want the Weight Loss Hypnosis Program designed for savvy savers like me who thrive in a "do-it-yourself" experience, with support available for me through the course’s Comments feature. — Single Payment of $267 or Two Monthly Payments of $147

D

Virtual Group Hypnotherapy Sessions for Weight Loss 8-Week Series. I want to leverage “social learning” in a supportive group atmosphere with like-minded people working on goals like mine. Includes live hypnosis each week, plus access to the complete 8-Week Online Course, "Lose Weight from Within" with all course materials and hypnosis reinforcement recordings. — Single Payment of $457 or Two Monthly Payments of $244 (Subject to Scheduling Availability)

E

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

F

This question doesn't apply to me.

Question 23 of 24

ADDITIONAL CONDITIONS 

The space below is for any Additional Conditions to be included in the agreement between you and Transformation Roadtrip LLC.  

 

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

Question 24 of 24

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 that, by entering my name and email at the end of this Online Intake assessment, I am giving my Electronic Consent in lieu of my physical signature effective the date of this completed assessment.

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 Hypnotherapy Consultation.

Confirm and Submit