Welcome and congratulations on taking the first step! Please review the Hypnosis Client Bill of Rights here.Please review the Service Information Agreement here. Please complete the form below in as much detail as possible. The more information you share with me, the better I can support you. Full Legal Name * First Name Last Name Date of Birth * MM DD YYYY Full Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Your Best Email Address * Referred by: Current Spouse/Partner * Name and number of years together: Children * Name(s) and current age: Occupation * (If student please share name of school and program of study.) What is your experience with coaching and therapy (if any)? * Please list all past and present health conditions in as much detail as possible: * Please describe your weekly physical activity in as much detail as possible: * How many times per week do you exercise? What types of exercise do you do? What types of exercise do you enjoy? How often would you like to exercise? Please list all past and present psychiatric conditions in as much detail as possible: * Please describe any fears/phobias in as much detail as possible: * Please list all current medications/supplements: * Include dosages if applicable. Approximately how much water do you drink per day? * Are you currently working with a medical professional on any of the above conditions? * Yes No Not applicable If appropriate, may I consult with your Physician or Therapist? * If so, please provide name, email address, and phone number. Do you smoke cigarettes or vape? * Yes No If yes, how much per day? How much alcohol do you consume on average per week? * Please rate your average weekly stress level: * 1 being nonexistent, 10 being extreme 1 2 3 4 5 6 7 8 9 10 Please rate your average weekly sleep quality: * 1 being worst possible, 10 being best possible 1 2 3 4 5 6 7 8 9 10 Please describe your experience (if any) with meditation in as much detail as possible: Have you been hypnotized before? Yes No Please describe your expectations of hypnosis in as much detail as possible: * What are three things you hope to achieve through hypnosis? * Please be as detailed as possible. Up until now, how have not achieving these goals negatively impacted your life? * How will achieving these goals positively impact your life? * Please share any additional pertinent information: I understand that good and lasting results may require several sessions and that I may be required to practice self-hypnosis and/or listen to a reinforcement recording between sessions/at home. I am resposible for actively cooperating with and participating in my program. Shelly Baca and Rising Earth Academy, LLC shall not be held accountable for the results I attain. I understand that my program may be terminated if deemed appropriate and that I may be referred elsewhere for proper treatment. I have read the Client Bill of Rights and I understand that all information about me will be kept strictly confidential. * I agree I do not agree I have reviewed the Client Bill of Rights linked at the top of this page. I understand that by checking "I agree" below I am submitting an electronic signature confirming I have thoroughly examined and understand the Client Bill of Rights. I agree I do not agree I have reviewed the Service Information Agreement linked at the top of this page. I understand that by checking "I agree" below I am submitting an electronic signature confirming I have thoroughly examined, understand, agree to abide by all terms of the Service Information Agreement. * I agree I do not agree Congratulations on taking the first step! I look forward to supporting you. Please email shelly@shellybaca.com with any questions or comments.