Health Declaration

Please fill out the following form
in order to participate in Hypnotherapy and/or Reiki sessions.

First Name

Last Name

Date of Birth

Please check the appropriate box to indicate your response and agreement to the following:

To the best of my knowledge, I do not have any serious physical, mental, or emotional disorders.

I have been diagnosed by a medical professional with the following condition(s):

Please list medical conditions here:

Please check the appropriate box to indicate your response and agreement to the following:

I am taking no medications. It is my responsibility to inform Bobbie Larson if my situation changes.

I am taking the following medications for physical or emotional conditions:

Please list medications here:

Initials

DISCLAIMER I understand Bobbie Larson’s services offered by her. I have discussed with Bobbie Larson the nature of the services to be provided. I understand it is my responsibility to maintain a relationship for myself/my dependent with a medical doctor, that Bobbie Larson routinely welcomes referrals from medical doctors, and that she will refer me to a medical doctor if requested. I have consented to use the Hypnotherapy and/or Reiki services of Bobbie Larson and agree to be personally responsible for the fees in connection with the services she provides me. I declare that the info I’ve provided is accurate & complete.

Thanks for submitting!