This form must be filled out in full before a session can be confirmed.

Date:_____________

First Name:________________________________

Last Name:________________________________

Address:__________________________________

City:______________________________________

State:_____________________________________

ZIp/Postal Code:____________________________

Day Phone Number:_________________________

Night Phone Number:________________________

E-Mail:____________________________________

Occupation:________________________________

Date of Birth:_______________________________

If you are currently under the care of a doctor or psychologist, do you have their permission for a hypnosis session with a Novus Minister?

Yes_____ No_____ Not Applicable_____

Do you have any medical conditions or psychological history that the Novus Minister should be aware of before the hypnosis session?

Yes_____ No_____ Not Applicable_____

If yes, please explain:

____________________________________

____________________________________

____________________________________

Have you ever been hypnotized and/or regressed?

Yes ___ No ___

If yes, when and describe your experience:

____________________________________

____________________________________

____________________________________

What do you want to accomplish with this session?

____________________________________

____________________________________

____________________________________

List the large cities near you that you are willing to travel to for this appointment:

____________________________________

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