CONFIDENTIAL - Client Information, Preliminary Questions, MEDICAL/HEALTH BACKGROUND and Agreement

Name *
Relationship Status *
How did you hear about Mindful Hypnotherapy of San Francisco? *
Here is a list of common difficulties which often lead people to seek professional assistance. Please check all that apply to you. *
Family History: Please check all that apply to your blood relatives. *
In requesting professional consultation and assistance, I understand that to be successful I must be entirely willing to: Recognize that my health and well-being depends directly on how well I care for myself emotionally, physically, intellectually and spiritually; Acknowledge that my feelings, thoughts, images and desires - conscious or subconscious - ultimately determine the course of every action and relationship in my life; Realize that blaming anything or anyone, including myself, is totally useless and that the only person I can take charge of in my life is me; Accept responsibility for myself, my choices and actions, and for life's outcomes as from day to day I, knowingly or unknowingly, create them; Agree to be on time for my appointments, meet my financial obligations promptly (1) pre-pay 24 hours in advance for appointment via Venmo or SquareCash and (2) pay $50 late fee if missed/rescheduled appointment within 24-hour notice, and participate wholeheartedly in the work I am undertaking. I know my heartfelt commitment is an important first step in my work here, and my signature below underscores that commitment. If, in all good conscience however, I cannot align myself fully with each statement above, I will decline signing at this time and agree to discuss in detail any reservations I may have.


In order to support you in deriving maximum benefit from our scheduled time together, I agree to:

  • Use the best of my abilities and expertise to facilitate such changes as are mutually agreed to be in your best interest and in no way harmful to you;

  • Work diligently to ensure as best I can that all suggestions given are positive in direction, beneficial in nature, and presented within a context of health and well-being;

  • Refrain from using you or your trust to satisfy any personal needs I may have outside the working relationship established here;

  • Offer you my undivided attention and professional assistance during our scheduled consultations;

  • Inform you immediately if, in my judgment, you would be better served by another professional or an alterative means of reaching your objectives.

I am professionally committed to assisting you - in the shortest possible time and at the lowest possible cost - in mobilizing your resources to achieve maximum results.

Kathleen Moore
Certified Hypnotherapist
Mindful Hypnotherapy of San Francisco